PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The department is reestablishing a noncovered services, eyeglasses, and contact lenses section (WAC 388-544-0575) which was previously repealed due to a lack of sufficient notice to stakeholders as required by the Administrative Procedure Act (APA). In addition to this, the department is relocating sections, updating cross references, adding the children's health program back in under eligibility, clarifying authorization requirements, including orthoptics and vision training therapy under covered services, requiring that all eyeglass lenses be placed into frames purchased by the department, limiting frequency of incidental repairs to eyeglass frames, and lowering the spherical requirement for high index lenses. When effective, this permanent rule replaces the emergency rule filed as WSR 08-11-048 filed on May 15, 2008.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-544-0450; and amending WAC 388-544-0010, 388-544-0050, 388-544-0100, 388-544-0150, 388-544-0250, 388-544-0300, 388-544-0350, 388-544-0400, 388-544-0500, 388-544-0550, and 388-544-0600.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: RCW 74.09.510, 74.09.520.
Adopted under notice filed as WSR 08-09-110 on April 21, 2008.
A final cost-benefit analysis is available by contacting Marlene Black, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1577, fax (360) 586-9727, e-mail blackml@dshs.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 11, Repealed 1.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 11, Repealed 1.
Date Adopted: June 24, 2008.
Robin Arnold-Williams
Secretary
3955.4(a) Covered;
(b) Within the scope of the eligible client's medical
care program; (((see WAC 388-501-0060 and 388-501-0065); and
(b))) (c) Medically necessary as defined in WAC 388-500-0005;
(d) Authorized, as required within this chapter, chapters 388-501 and 388-502 WAC, and the department's published billing instructions and numbered memoranda; and
(e) Billed according to this chapter, chapters 388-501 and 388-502 WAC, and the department's published billing instructions and numbered memoranda.
(2) The department ((evaluates a request for any service
that is listed as noncovered in this chapter under the
provisions of WAC 388-501-0160)) does not require prior
authorization for covered vision care services that meet the
clinical criteria set forth in this chapter.
(3) The department ((evaluates requests for covered
services that are subject to limitations or other restrictions
and approves such services beyond those limitations or
restrictions under the provisions of WAC 388-501-0169))
requires prior authorization for covered vision care services
when the clinical criteria set forth in this chapter are not
met, including the criteria associated with the expedited
prior authorization process. The department evaluates these
requests on a case-by-case basis to determine whether they are
medically necessary, according to the process found in WAC 388-501-0165.
(((4) The department evaluates a request for a service
that is in a covered category, but has been determined to be
experimental or investigational under WAC 388-531-0550, under
the provisions of WAC 388-501-0165.))
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-544-0010, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0010, filed 6/6/05, effective 7/7/05.]
"Blindness" - A diagnosis of visual acuity for distance vision of twenty/two hundred or worse in the better eye with best correction or a limitation of the client's visual field (widest diameter) subtending an angle of less than twenty degrees from central.
"Conventional soft contact lenses" or "rigid gas
permeable contact lenses" - FDA-approved contact lenses that
do not have a scheduled replacement (discard and replace with
new contacts) plan. The soft lenses usually last one year,
and the rigid gas permeable lenses usually last two years.
Although some of these lenses are designed for extended wear,
((MAA)) the department generally approves only those lenses
that are designed to be worn as daily wear (remove at night).
"Disposable contact lenses" - FDA-approved contact lenses
that have a planned replacement schedule (e.g., daily, every
two weeks, monthly, quarterly). The contacts are then
discarded and replaced with new ones as scheduled. Although
many of these lenses are designed for extended wear, ((MAA))
the department generally approves only those lenses that are
designed to be worn as daily wear (remove at night).
"Expedited prior authorization" - A form of authorization used by the provider to certify that the department-published clinical criteria for a specific vision care service(s) have been met.
"Extended wear soft contacts" - Contact lenses that are designed to be worn for longer periods than daily wear (remove at night) lenses. These can be conventional soft contact lenses or disposable contact lenses designed to be worn for several days and nights before removal.
"Hardware" - Eyeglass frames and lenses and contact lenses.
"Prior authorization" - A form of authorization used by the provider to obtain the department's written approval for a specific vision care service(s). The department's approval is based on medical necessity and must be received before the service(s) are provided to clients as a precondition for payment.
"Specialty contact lens design" - Custom contact lenses that have a more complex design than a standard spherical lens. These specialty contact lenses (e.g., lenticular, aspheric, or myodisc) are designed for the treatment of specific disease processes, such as keratoconus, or are required due to high refractive errors. This definition of specialty contact lens does not include lenses used for surgical implantation.
"Stable visual condition" - A client's eye condition has no acute disease or injury; or the client has reached a point after any acute disease or injury where the variation in need for refractive correction has diminished or steadied. The client's vision condition has stabilized to the extent that eyeglasses or contact lenses are appropriate and that any prescription for refractive correction is likely to be sufficient for one year or more.
"Visual field exams or testing" - A process to determine defects in the field of vision and test the function of the retina, optic nerve and optic pathways. The process may include simple confrontation to increasingly complex studies with sophisticated equipment.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0050, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0050, filed 12/6/00, effective 1/6/01.]
(a) Categorically needy program (CN or CNP);
(b) Categorically needy program - state children's health insurance program (CNP-SCHIP);
(c) Children's healthcare programs as defined in WAC 388-505-0210;
(d) Limited casualty program - medically needy program (LCP-MNP);
(((d))) (e) General assistance (GA-U/ADATSA) (within
Washington state or designated border cities); and
(((e))) (f) Emergency medical only programs when the
services are directly related to an emergency medical
condition only.
(2) Clients who are enrolled in ((an MAA managed care
plan)) a department-contracted managed care organization (MCO)
are eligible under fee-for-service for covered vision care
services that are not covered by their plan((,)) and subject
to the provisions of this chapter ((388-544 WAC)) and other
applicable WAC.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0100, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0100, filed 12/6/00, effective 1/6/01.]
(a) Meet the requirements in chapter 388-502 WAC;
(b) Provide only those services that are within the scope of the provider's license;
(c) Obtain all hardware (including the tinting of
eyeglass lenses) and contact lenses for ((MAA)) clients from
((MAA's contracted)) the department's designated supplier as
published in the department's current vision care billing
instructions; and
(d) Return all unclaimed hardware and contact lenses to
((MAA's contracted)) the department's designated supplier
using a postage-paid envelope furnished by the ((contractor))
supplier.
(2) The following providers are eligible to
enroll/contract with ((MAA)) the department to provide and
bill for vision care services furnished to eligible clients:
(a) Ophthalmologists;
(b) Optometrists;
(c) Opticians; and
(d) Ocularists.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0150, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0150, filed 12/6/00, effective 1/6/01.]
(a) For clients twenty-one years of age or older, once every twenty-four months;
(b) For clients twenty years of age or younger, once every twelve months; or
(c) For clients with developmental disabilities, regardless of age, once every twelve months.
(2) MAA covers eye examinations and refraction services as often as medically necessary when:
(a) The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease; or
(b) The client is on medication that affects vision.
(3) MAA covers eye examinations/refractions outside the time limitations in subsection (1) of this section when the eye examination/refraction is necessary due to lost or broken eyeglasses/contacts. In this situation, MAA does not require authorization for children. To receive payment for an adult client, providers must:
(a) Follow the expedited prior authorization process; and
(b) Document the following in the client's file:
(i) The eyeglasses or contacts are lost or broken; and
(ii) The last examination was at least eighteen months ago.
(4) MAA covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. To receive payment, providers must document all of the following in the client's record:
(a) The extent of the testing;
(b) Why the testing was reasonable and necessary for the client; and
(c) The medical basis for the frequency of testing)) The department covers, without prior authorization, eye examinations and refraction services with the following limitations:
(a) Once every twenty-four months for asymptomatic clients twenty-one years of age or older;
(b) Once every twelve months for asymptomatic clients twenty years of age or younger; or
(c) Once every twelve months, regardless of age, for asymptomatic clients of the division of developmental disabilities.
(2) The department covers additional examinations and refraction services outside the limitations described in subsection (1) of this section when:
(a) The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease;
(b) The client is on medication that affects vision; or
(c) The service is necessary due to lost or broken eyeglasses/contacts. In this case:
(i) No type of authorization is required for clients twenty years of age or younger or for clients of the division of developmental disabilities, regardless of age.
(ii) Providers must follow the department's expedited prior authorization process to receive payment for clients twenty-one years of age or older. Providers must also document the following in the client's file:
(A) The eyeglasses or contacts are lost or broken; and
(B) The last examination was at least eighteen months ago.
(3) The department covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. Providers must document all of the following in the client's record:
(a) The extent of the testing;
(b) Why the testing was reasonable and necessary for the client; and
(c) The medical basis for the frequency of testing.
(4) The department covers orthoptics and vision training therapy. Providers must obtain prior authorization from the department.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0250, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0250, filed 12/6/00, effective 1/6/01.]
(a) Under the following conditions and limitations:
(i) For clients twenty-one years of age or older, once every twenty-four months;
(ii) For clients twenty years of age or younger, once every twelve months; or
(iii) For clients with developmental disabilities, regardless of age, once every twelve months.
(b) When:
(i) The client has a stable visual condition;
(ii) The client's treatment is stabilized;
(iii) The prescription is less than eighteen months old; and
(iv) One of the following minimum correction needs in a least one eye is documented in the client's file:
(A) Sphere power equal to, or greater than, plus or minus 0.50 diopter;
(B) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or
(C) Add power equal to, or greater than, 1.0 diopter for bifocals and trifocals.
(2) MAA covers eyeglasses and/or lenses for clients who are twenty years of age or younger with a diagnosis of accommodative esotropia or any strabismus correction. In this situation, the client is not subject to the requirements in subsection (1)(b) of this section.
(3) MAA covers selected frames called "durable" or "flexible" frames through MAA's contracted supplier when a client has a diagnosed medical condition that has contributed to two or more broken eyeglass frames in a twelve-month period. To receive payment, providers must follow the expedited prior authorization process.
(4) MAA covers the cost of coating contract eyeglass frames to make the frames nonallergenic if the client has a medically diagnosed and documented allergy to the materials in the available eyeglass frames.
(5) MAA pays for incidental repairs to a client's eyeglass frames when all of the following apply:
(a) The provider typically charges the general public for the repair or adjustment;
(b) The contractor's one year warranty period has expired; and
(c) The cost of the repair does not exceed MAA's cost for replacement frames.
(6) MAA covers replacement eyeglass frames and/or lenses that have been lost or broken. To receive payment, providers must follow the expedited prior authorization process for clients twenty-one years of age and older. MAA does not require authorization for clients who are twenty years of age and younger or for clients with developmental disabilities, regardless of age. (See WAC 388-544-0350 for additional coverage of lens replacement.)
(7) MAA covers one pair of back-up eyeglasses when contact lenses are medically necessary and the contact lenses are the client's primary visual correction aid as described in WAC 388-544-0400(1). MAA limits coverage for back-up eyeglasses as follows:
(a) For clients twenty-one years of age and older, once every six years;
(b) For clients twenty years of age or younger, once every two years; or
(c) For clients with developmental disabilities, regardless of age, once every two years)) The department covers eyeglasses, without prior authorization, as follows:
(a) When the following clinical criteria are met:
(i) The client has a stable visual condition;
(ii) The client's treatment is stabilized;
(iii) The prescription is less than eighteen months old; and
(iv) One of the following minimum correction needs in at least one eye is documented in the client's file:
(A) Sphere power equal to, or greater than, plus or minus 0.50 diopter;
(B) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or
(C) Add power equal to, or greater than, 1.0 diopter for bifocals and trifocals.
(b) With the following limitations:
(i) Once every twenty-four months for clients twenty-one years of age or older;
(ii) Once every twelve months for clients twenty years of age or younger; or
(iii) Once every twelve months, regardless of age, for clients of the division of developmental disabilities.
(2) The department covers eyeglasses (frames/lenses), without prior authorization, for clients who are twenty years of age or younger with a diagnosis of accommodative esotropia or any strabismus correction. In this case, the limitations of subsection (1) of this section do not apply.
(3) The department covers one pair of back-up eyeglasses for clients who wear contact lenses as their primary visual correction aid (see WAC 388-544-0400(1)) with the following limitations:
(a) Once every six years for clients twenty years of age or older;
(b) Once every two years for clients twenty years of age or younger or regardless of age for clients of the division of developmental disabilities.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0300, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0300, filed 12/6/00, effective 1/6/01.]
(a) Follow the department's expedited prior authorization process; and
(b) Order the "durable" or "flexible" frames through the department's designated supplier.
(2) The department covers all of the following without prior authorization:
(a) Coating contract eyeglass frames to make the frames nonallergenic. Clients must have a medically diagnosed and documented allergy to the materials in the available eyeglass frames.
(b) Incidental repairs to a client's eyeglass frames. To receive payment, all of the following must be met:
(i) The provider typically charges the general public for the repair or adjustment;
(ii) The contractor's one year warranty period has expired;
(iii) The cost of the repair does not exceed the department's cost for replacement frames and a fitting fee; and
(iv) The frequency of the repair does not exceed two per client in a six-month period. This limit does not apply to clients twenty years of age or younger or to clients of the division of developmental disabilities, regardless of age.
(3) The department covers replacement eyeglass frames that have been lost or broken as follows:
(a) No type of authorization is required for clients twenty years of age or younger or for clients of the division of developmental disabilities, regardless of age.
(b) To receive payment for clients twenty-one years of age or older, excluding clients of the division of developmental disabilities, providers must follow the department's expedited prior authorization process.
[]
(a) Single vision lenses;
(b) Round or flat top D-style bifocals;
(c) Flat top trifocals; and
(d) Slab-off and prism lenses (including Fresnel lenses).
(2) ((MAA allows bifocal lenses to be replaced with
single vision or trifocal lenses or trifocal lenses to be
replaced with bifocal or single vision lenses when all of the
following apply:
(a) A client has attempted to adjust to the bifocals or trifocals for at least sixty days;
(b) The client is unable to make the adjustment; and
(c) The bifocal or trifocal lenses being replaced are returned to the provider.
(3) MAA covers high index lenses for clients who require one of the following in at least one eye:
(a) A spherical refractive correction of plus or minus eight diopters or greater; or
(b) A cylinder correction of plus or minus three diopters or greater.
To receive payment, providers must follow the expedited prior authorization process.
(4) MAA covers the tinting of plastic lenses through MAA's contracted lens supplier. The client's medical need must be diagnosed and documented as one or more of the following chronic (expected to last longer than three months) eye conditions causing photophobia:
(a) Blindness;
(b) Chronic corneal keratitis;
(c) Chronic iritis, iridocyclitis;
(d) Diabetic retinopathy;
(e) Fixed pupil;
(f) Glare from cataracts;
(g) Macular degeneration;
(h) Migraine disorder;
(i) Ocular albinism;
(j) Optic atrophy and/or optic neuritis;
(k) Rare photo-induced epilepsy conditions; or
(l) Retinitis pigmentosa.
(5) MAA covers plastic photochromatic lenses when the client's medical need is diagnosed as relating to ocular albinism or retinitis pigmentosa.
(6) MAA covers polycarbonate lenses as follows:
(a) For clients who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required;
(b) Infants and toddlers with motor ataxia;
(c) For clients twenty years of age or younger who are diagnosed with strabismus or amblyopia; or
(d) For clients with developmental disabilities.
(7) MAA covers requests for lenses only when the client owns frames not purchased by MAA, when:
(a) The eyeglass frames are serviceable (MAA and MAA's contractor do not accept responsibility for these frames); and
(b) The size and style of the required lenses meet MAA's contract requirements.
(8) MAA covers replacement lenses as follows:
(a) Due to lost or broken lenses according to WAC 388-544-0300(6); and
(b) Due to refractive changes, without regard to time limits, when caused by one of the following:
(i) Eye surgery, the effects of prescribed medication, or one or more diseases affecting vision. In this case, all of the following must be documented in the client's file:
(A) The client has a stable visual condition;
(B) The client's treatment is stabilized;
(C) The lens correction must have a 1.0 or greater diopter change between the sphere or cylinder correction in at least one eye; and
(D) The previous and new refraction.
(ii) Headaches, blurred vision, or difficulty with school or work. In this case, all of the following must be documented in the client's file:
(A) Copy of current prescription (less than eighteen months old);
(B) Date of last dispensing, if known;
(C) Absence of a medical condition that is known to cause temporary visual acuity changes (e.g., diabetes, pregnancy, etc.); and
(D) A refractive change of at least .75 diopter or greater between the sphere or cylinder correction in at least one eye.
(c) To receive payment for replacement lenses, providers must follow the expedited prior authorization process)) Eyeglass lenses, as described in subsection (1) of this section must be placed into a frame that is, or was, purchased by the department.
(3) The department covers, without prior authorization, the following lenses when the clinical criteria are met:
(a) High index lenses. Providers must follow the department's expedited prior authorization process. The client's medical need in at least one eye must be diagnosed and documented as:
(i) A spherical refractive correction of plus or minus six diopters or greater; or
(ii) A cylinder correction of plus or minus three diopters or greater.
(b) Plastic photochromatic lenses. The client's medical need must be diagnosed and documented as ocular albinism or retinitis pigmentosa.
(c) Polycarbonate lenses. The client's medical need must be diagnosed and documented as one of the following:
(i) Blind in one eye and needs protection for the other eye, regardless of whether a vision correction is required;
(ii) Infants and toddlers with motor ataxia;
(iii) Strabismus or amblyopia for clients twenty years of age or younger; or
(iv) For clients of the division of developmental disabilities.
(d) Bifocal lenses to be replaced with single vision or trifocal lenses, or trifocal lenses to be replaced with bifocal or single vision lenses when:
(i) The client has attempted to adjust to the bifocals or trifocals for at least sixty days; and
(ii) The client is unable to make the adjustment; and
(iii) The trifocal lenses being replaced are returned to the provider.
(4) The department covers, without prior authorization, the tinting of plastic lenses when the client's medical need is diagnosed and documented as one or more of the following chronic (expected to last longer than three months) eye conditions causing photophobia:
(a) Blindness;
(b) Chronic corneal keratitis;
(c) Chronic iritis, iridocyclitis;
(d) Diabetic retinopathy;
(e) Fixed pupil;
(f) Glare from cataracts;
(g) Macular degeneration;
(h) Migraine disorder;
(i) Ocular albinism;
(j) Optic atrophy and/or optic neuritis;
(k) Rare photo-induced epilepsy conditions; or
(l) Retinitis pigmentosa.
(5) The department covers replacement lenses when the lenses are lost or broken as follows:
(a) No type of authorization is required for clients twenty years of age and younger or for clients of the division of developmental disabilities, regardless of age.
(b) Providers must follow the expedited prior authorization process to receive payment for clients twenty-one years of age or older.
(6) The department covers replacement lenses, without prior authorization, when the client meets one of the clinical criteria. To receive payment, providers must follow the expedited prior authorization process. The clinical criteria are:
(a) Eye surgery or the effects of prescribed medication or one or more diseases affecting vision:
(i) The client has a stable visual condition;
(ii) The client's treatment is stabilized;
(iii) The lens correction must have a 1.0 or greater diopter change between the sphere or cylinder correction in at least one eye; and
(iv) The previous and new refraction are documented in the client's record.
(b) Headaches, blurred vision, or visual difficulty in school or at work. In this case, all of the following must be documented in the client's file:
(i) Copy of current prescription (less than eighteen months old);
(ii) Date of last dispensing, if known;
(iii) Absence of a medical condition that is known to cause temporary visual acuity changes (e.g., diabetes, pregnancy, etc.); and
(iv) A refractive change of at least .75 diopter or greater between the sphere or cylinder correction in at least one eye.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, and 42 C.F.R. 440.120 and 440.225. 05-17-153, § 388-544-0350, filed 8/22/05, effective 9/22/05; 05-13-038, § 388-544-0350, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0350, filed 12/6/00, effective 1/6/01.]
(a) Conventional soft contact lenses or rigid gas permeable contact lenses that are prescribed for daily wear; or
(b) Disposable contact lenses that are prescribed for daily wear and have a monthly or quarterly planned replacement schedule, as follows:
(i) Twelve pairs of monthly replacement contact lenses; or
(ii) Four pairs of three-month replacement contact lenses.
(2) For clients diagnosed with high anisometropia, MAA covers the contact lenses in subsection (1) of this section when the client's refractive error difference between the two eyes is plus or minus 3.0 diopters and eyeglasses cannot reasonably correct the refractive errors.
(3) A client who qualifies for contact lenses as the primary refractive correction method must choose one style of contact lenses from those listed in subsection (1) of this section for each twelve-month period of coverage.
(4) MAA covers soft toric contact lenses for clients with astigmatism requiring a cylinder correction of plus or minus 1.0 diopter in at least one eye and the client also meets the spherical correction listed in subsection (1) of this section.
(5) MAA covers specialty contact lens designs for clients who are diagnosed with one or more of the following:
(a) Aphakia;
(b) Keratoconus; or
(c) Corneal softening.
(6) MAA covers replacement contact lenses as follows:
(a) Once every twelve months for lost or damaged contact lenses; or
(b) As often as medically necessary when all of the following apply:
(i) One of the following caused the vision change:
(A) Eye surgery;
(B) The effect(s) of prescribed medication; or
(C) One or more diseases affecting vision.
(ii) The client has a stable visual condition;
(iii) The client's treatment is stabilized; and
(iv) The lens correction has a 1.0 or greater diopter change in at least one eye between the sphere or cylinder correction. The previous and new refraction must be documented in the client's record.
(c) To receive payment for adults, providers must follow the expedited prior authorization process. Prior authorization is not required for children or for clients with developmental disabilities.
(7) MAA covers therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery)) The department covers contact lenses, without prior authorization, as the client's primary refractive correction method when the client has a spherical correction of plus or minus 6.0 diopters or greater in at least one eye. See subsection (4) of this section for exceptions to the plus or minus 6.0 diopter criteria. The spherical correction may be from the prescription for the glasses or the contact lenses and may be written in either "minus cyl" or "plus cyl" form.
(2) The department covers the following contact lenses with limitations:
(a) Conventional soft contact lenses or rigid gas permeable contact lenses that are prescribed for daily wear; or
(b) Disposable contact lenses that are prescribed for daily wear and have a monthly or quarterly planned replacement schedule, as follows:
(i) Twelve pairs of monthly replacement contact lenses; or
(ii) Four pairs of three-month replacement contact lenses.
(3) The department covers soft toric contact lenses, without prior authorization, for clients with astigmatism when the following clinical criteria are met:
(a) The client's cylinder correction is plus or minus 1.0 diopter in at least one eye; and
(b) The client meets the spherical correction listed in subsection (1) of this section.
(4) The department covers contact lenses, without prior authorization, when the following clinical criteria are met. In these cases, the limitations in subsection (1) of this section do not apply.
(a) For clients diagnosed with high anisometropia.
(i) The client's refractive error difference between the two eyes is at least plus or minus 3.0 diopters; and
(ii) Eyeglasses cannot reasonably correct the refractive errors.
(b) Specialty contact lens designs for clients who are diagnosed with one or more of the following:
(i) Aphakia;
(ii) Keratoconus; or
(iii) Corneal softening.
(c) Therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery.
(5) The department covers replacement contact lenses, limited to once every twelve months, when lost or damaged as follows:
(a) Authorization is not required for clients twenty years of age or younger or for clients of the division of developmental disabilities, regardless of age.
(b) Providers must follow the expedited prior authorization process to receive payment for clients twenty-one years of age or older.
(6) The department covers replacement contact lenses when all of the clinical criteria are met:
(a) The clinical criteria are:
(i) One of the following caused the vision change:
(A) Eye surgery;
(B) The effect(s) of prescribed medication; or
(C) One or more diseases affecting vision.
(ii) The client has a stable visual condition;
(iii) The client's treatment is stabilized; and
(iv) The lens correction has a 1.0 or greater diopter change in at least one eye between the sphere or cylinder correction. The previous and new refraction must be documented in the client's record.
(b) No type of authorization is required for clients twenty years of age and younger or for clients of the division of developmental disabilities, regardless of age.
(c) To receive payment for clients twenty-one years of age or older, providers must follow the expedited prior authorization process.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0400, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0400, filed 12/6/00, effective 1/6/01.]
(1) An ophthalmologist;
(2) An ocularist; or
(3) An optometrist who specializes in ((orthotics))
prosthetics.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0500, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0500, filed 12/6/00, effective 1/6/01.]
(a) It is included in the scope of care for the client's medical program;
(b) It is medically necessary as defined in subsection (2) of this section; and
(c) The provider clearly documents the need in the client's record.
(2) MAA considers cataract surgery to be medically necessary when the client has:
(a) Correctable visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen test chart; or
(b) One or more of the following conditions:
(i) Dislocated or subluxated lens;
(ii) Intraocular foreign body;
(iii) Ocular trauma;
(iv) Phacogenic glaucoma;
(v) Phacogenic uveitis;
(vi) Phacoanaphylactic endopthalmitis; or
(vii) Increased ocular pressure in a person who is blind and is experiencing ocular pain.
(3) MAA covers strabismus surgery as follows:
(a) For clients seventeen years of age and younger, when medically necessary. The provider must clearly document the need in the client's record.
(b) For clients eighteen years of age and older when:
(i) The client has double vision; and
(ii) The surgery is not performed for cosmetic reasons.
(c) To receive payment for clients eighteen years of age and older, providers must follow MAA's expedited prior authorization process listed in WAC 388-544-0450. MAA does not require authorization for clients seventeen years of age and younger.
(4) MAA covers blepharoplasty or blepharoptosis surgery for noncosmetic reasons when:
(a) The excess upper eyelid skin impairs the vision by blocking the superior visual field; and
(b) The vision is blocked to within ten degrees of central fixation using a central visual field test)) department covers cataract surgery, without prior authorization, when the following clinical criteria are met:
(a) Correctable visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen test chart; or
(b) One or more of the following conditions:
(i) Dislocated or subluxated lens;
(ii) Intraocular foreign body;
(iii) Ocular trauma;
(iv) Phacogenic glaucoma;
(v) Phacogenic uveitis;
(vi) Phacoanaphylactic endopthalmitis; or
(vii) Increased ocular pressure in a person who is blind and is experiencing ocular pain.
(2) The department covers strabismus surgery as follows:
(a) For clients seventeen years of age and younger. The provider must clearly document the need in the client's record. The department does not require authorization for clients seventeen years of age and younger; and
(b) For clients eighteen years of age and older, when the clinical criteria are met. To receive payment, providers must follow the expedited prior authorization process. The clinical criteria are:
(i) The client has double vision; and
(ii) The surgery is not being performed for cosmetic reasons.
(3) The department covers blepharoplasty or blepharoptosis surgery when all of the clinical criteria are met. To receive payment, providers must follow the department's expedited prior authorization process. The clinical criteria are:
(a) The client's excess upper eyelid skin is blocking the superior visual field; and
(b) The blocked vision is within ten degrees of central fixation using a central visual field test.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0550, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0550, filed 12/6/00, effective 1/6/01.]
(a) For prior authorization (PA), a provider must submit a written request to the department as specified in the department's published vision care billing instructions.
(b) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the department's published vision care billing instructions. The appropriate EPA number must be used when the provider bills the department.
(c) Upon request, a provider must provide documentation to the department showing how the client's condition met the criteria for PA or EPA.
(2) Authorization requirements in this chapter are not a denial of service.
(3) When a service requires authorization, the provider must properly request authorization in accordance with the department's rules, billing instructions, and numbered memoranda.
(4) When authorization is not properly requested, the department rejects and returns the request to the provider for further action. The department does not consider the rejection of the request to be a denial of service.
(5) The department's authorization of service(s) does not necessarily guarantee payment.
(6) The department evaluates requests for authorization of covered vision care services that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 388-501-0169.
(7) The department may recoup any payment made to a provider if the department later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 388-502-0100 (1)(c).
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(a) Executive style eyeglass lenses;
(b) Bifocal contact lenses;
(c) Daily and two week disposable contact lenses;
(d) Extended wear soft contact lenses, except when used as therapeutic contact bandage lenses or for aphakic clients;
(e) Custom colored contact lenses;
(f) Services for cosmetic purposes only;
(g) Glass lenses;
(h) Group vision screening for eyeglasses;
(i) Nonglare or anti-reflective lenses;
(j) Progressive lenses;
(k) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens corrections. This does not include intraocular lens implantation following cataract surgery.
(l) Sunglasses and accessories that function as sunglasses (e.g., "clip-ons");
(m) Upgrades at private expense to avoid the department's contract limitations (e.g., frames that are not available through the department's contract or noncontract frames or lenses for which the client or other person pays the difference between the department's payment and the total cost).
(2) An exception to rule (ETR), as described in WAC 388-501-0160, may be requested for a noncovered service.
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(2) ((MAA covers)) The department pays one hundred
percent of the ((MAA)) department contract price for covered
eyeglass frames, lenses, and contact lenses when these items
are obtained through ((MAA's)) the department's approved
((contract(s))) contractor.
(3) See WAC 388-531-1850 for professional fee payment methodology.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0600, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0600, filed 12/6/00, effective 1/6/01.]
The following section of the Washington Administrative Code is repealed:
| WAC 388-544-0450 | Vision care -- Prior authorization. |