PDFWAC 182-544-0350

Vision care—Covered eyeglass lenses—Clients age twenty and younger.

(1) The medicaid agency covers the following plastic scratch-resistant eyeglass lenses:
(a) Single vision lenses;
(b) Round or flat top D-style bifocals;
(c) Flat top trifocals;
(d) Slab-off and prism lenses (including Fresnel lenses);
(e) Plastic photochromatic lenses when the client's medical need is diagnosed and documented as ocular albinism or retinitis pigmentosa;
(f) Polycarbonate lenses when the client's medical need is 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;
(iv) Seizure disorder, cerebral palsy, autism, attention deficit hyperactivity disorder (ADHD), developmental delay, Down syndrome, bipolar, schizophrenia, or multiple sclerosis.
(g) 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;
(ii) The client is unable to make the adjustment; and
(iii) The trifocal lenses being replaced are returned to the provider.
(2) Eyeglass lenses covered under subsection (1) of this section must be placed into a frame that is, or was, purchased by the agency.
(3) The agency covers the following high index lenses for clients when clinical criteria are met. The client's medical need in at least one eye must be diagnosed and documented as:
(a) A spherical refractive correction of plus or minus six diopters or greater; or
(b) A cylinder correction of plus or minus three diopters or greater.
(4) The agency covers 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 or optic neuritis;
(k) Rare photo-induced epilepsy conditions; or
(l) Retinitis pigmentosa.
(5) The agency covers up to four replacement lenses in a calendar year when the lenses are lost or broken. Lost or broken lenses must be documented in the client's medical record.
(6) The agency covers replacement lenses when the client meets one of the following clinical criteria:
(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 medical 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 medical record:
(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 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0350, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0350, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 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. WSR 05-17-153, § 388-544-0350, filed 8/22/05, effective 9/22/05; WSR 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. WSR 01-01-010, § 388-544-0350, filed 12/6/00, effective 1/6/01.]