WSR 11-11-016

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed May 9, 2011, 8:50 a.m. , effective June 9, 2011 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: Upon order of the governor, the medicaid purchasing administration (MPA) must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. To achieve this expenditure reduction, MPA is eliminating the following optional medical service(s) for adults twenty-one years of age and older: Eyeglass frames, lenses, and contact lenses.

Citation of Existing Rules Affected by this Order: Amending WAC 388-544-0100, 388-544-0250, 388-544-0300, 388-544-0325, 388-544-0350, 388-544-0400, 388-544-0500, 388-544-0550, and 388-544-0575.

Statutory Authority for Adoption: RCW 74.08.090.

Adopted under notice filed as WSR 11-07-082 on March 22, 2011.

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 Marlene.Black@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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 9, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 9, Repealed 0.

Date Adopted: May 9, 2011.

Susan N. Dreyfus

Secretary

4256.7VISION CARE-CLIENTS TWENTY YEARS OF AGE AND YOUNGER
AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0100   Vision care -- Eligible clients--Twenty years of age and younger.   This section applies to eligible clients who are twenty years of age and younger.

(1) Vision care ((services are)) is available to clients who are eligible for services under the following medical assistance programs ((only)):

(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);

(e) Disability lifeline (formerly general assistance (GA-U/ADATSA)) (within Washington state or designated border cities); and

(f) ((Emergency medical only programs when the services are directly related to an)) Alien emergency medical (AEM) as described in WAC 388-438-0115, when the medical services are necessary to treat a qualifying emergency medical condition only.

(2) Eligible clients who are enrolled in 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 and other applicable WAC.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0100, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0250   Vision care -- Covered eye services (examinations, refractions, visual field testing, and vision therapy).   (((1) 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)) See WAC 388-531-1000 Ophthalmic services.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0250, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0300   Vision care -- Covered eyeglasses (frames and/or lenses) and repair ((services))--Clients twenty years of age and younger.   This section applies to eligible clients who are twenty years of age and younger.

(1) The department covers eyeglasses, without prior authorization, ((as follows:

(a))) once every twelve months for eligible clients when the following clinical criteria are met:

(((i))) (a) The eligible client has a stable visual condition;

(((ii))) (b) The eligible client's treatment is stabilized;

(((iii))) (c) The prescription is less than eighteen months old; and

(((iv))) (d) One of the following minimum correction needs in at least one eye is documented in the client's file:

(((A))) (i) Sphere power equal to, or greater than, plus or minus 0.50 diopter;

(((B))) (ii) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or

(((C))) (iii) 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 eligible clients ((who are twenty years of age or younger)) with a diagnosis of accommodative esotropia or any strabismus correction, without prior authorization. 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 eligible 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))) limited to once every two years for eligible 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. 08-14-052, 388-544-0300, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0325   Vision care--Covered eyeglass frames--Clients twenty years of age and younger.   This section applies to eligible clients who are twenty years of age and younger.

(1) The department covers durable or flexible frames, without prior authorization, when the eligible client has a diagnosed medical condition that has contributed to two or more broken eyeglass frames in a twelve-month period. To receive payment, the provider must:

(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 for eligible clients without prior authorization:

(a) Coating contract eyeglass frames to make the frames nonallergenic. Eligible 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; and

(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)).

(c) Replacement eyeglass frames that have been lost or broken.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0325, filed 6/24/08, effective 7/25/08.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0350   Vision care -- Covered eyeglass lenses ((and services))--Clients twenty years of age and younger.   This section applies to eligible clients who are twenty years of age and younger.

(1) The department covers the following plastic scratch-resistant eyeglass lenses without prior authorization:

(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) 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 for eligible clients when the clinical criteria are met:

(a) High index lenses. Providers must follow the department's expedited prior authorization process. The eligible 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 eligible client's medical need must be diagnosed and documented as ocular albinism or retinitis pigmentosa.

(c) Polycarbonate lenses. The eligible 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 eligible client has attempted to adjust to the bifocals or trifocals for at least sixty days; and

(ii) The eligible 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 eligible 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 for eligible clients without prior authorization 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 eligible 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. 08-14-052, 388-544-0350, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0400   Vision care -- Covered contact lenses ((and services))--Clients twenty years of age and younger.   This section applies to eligible clients who are twenty years of age and younger.

(1) The department covers contact lenses, without prior authorization, as the eligible client's primary refractive correction method when the eligible 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 eligible clients with astigmatism when the following clinical criteria are met:

(a) The eligible client's cylinder correction is plus or minus 1.0 diopter in at least one eye; and

(b) The eligible 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 eligible clients diagnosed with high anisometropia.

(i) The eligible client's refractive error difference between the two eyes is at least plus or minus 3.0 diopters between the sphere or cylinder correction; and

(ii) Eyeglasses cannot reasonably correct the refractive errors.

(b) Specialty contact lens designs for eligible 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,)) for eligible clients 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. 08-14-052, 388-544-0400, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0500   Vision care -- Covered ocular prosthetics.   ((The department covers ocular prosthetics when provided by any of the following:

(1) An ophthalmologist;

(2) An ocularist; or

(3) An optometrist who specializes in prosthetics)) See WAC 388-531-1000 Opthalmic services.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0500, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0550   Vision care -- Covered eye surgery.   (((1) The 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)) See WAC 388-531-1000 Opthalmic services.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0550, filed 6/24/08, effective 7/25/08. 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.]


AMENDATORY SECTION(Amending WSR 08-14-052, filed 6/24/08, effective 7/25/08)

WAC 388-544-0575   Vision care--Noncovered ((services,)) eyeglasses((,)) and contact lenses.   (1) The department does not cover the following:

(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))) (g) Nonglare or anti-reflective lenses;

(((j))) (h) 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))) (i) Sunglasses and accessories that function as sunglasses (e.g., "clip-ons");

(((m))) (j) 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.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, 388-544-0575, filed 6/24/08, effective 7/25/08.]

Washington State Code Reviser's Office