WSR 14-17-049
[Insurance Commissioner Matter No. R 2014-04Filed August 14, 2014, 4:36 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 14-11-107.
Title of Rule and Other Identifying Information: Pediatric routine vision screening.
Hearing Location(s): Office of the Insurance Commissioner, Training Room (TR-120), 5000 Capitol Boulevard S.E., Tumwater, WA, on September 29, 2014, at 9:00 a.m.
Date of Intended Adoption: October 1, 2014.
Submit Written Comments to: Kate Reynolds, P.O. Box 40258, Olympia, WA 98504-0258, e-mail, fax (360) 586-3109, by September 26, 2014.
Assistance for Persons with Disabilities: Contact Lori [Lorie] Villaflores by September 26, 2014, TTY (360) 586-0241 or (360) 725-7087.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Pediatric routine vision screening was defined in the rule making regarding essential health benefits. The current definition was evaluated based on what services are included in a routine vision screening and what services are included in a comprehensive eye exam.
Reasons Supporting Proposal: The revised definition separates routine vision screening and comprehensive vision screening for clarification for issuers and consumers.
Statutory Authority for Adoption: RCW 48.02.060, 48.44.050, 48.46.200.
Statute Being Implemented: RCW 48.43.715.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Mike Kreidler, insurance commissioner, governmental.
Name of Agency Personnel Responsible for Drafting: Kate Reynolds, P.O. Box 40258, Olympia, WA 98504-0258, (360) 725-7170; Implementation: Molly Nollette, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7117; and Enforcement: AnnaLisa Gellermann, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The entities that must comply with the proposed rule are not small businesses, pursuant to chapter 19.85 RCW.
A cost-benefit analysis is not required under RCW 34.05.328. This proposed rule revision is a clarification of an essential health benefit as specified in the Affordable Care Act and follows federal guidance established in the federal employees dental and vision insurance program. This clarification identifies dilation and refraction testing as distinct benefits separate from routine vision screening and included under a comprehensive eye exam. Therefore, under the provisions of RCW 34.05.328 (5)(iii), no cost-benefit analysis is required.
August 14, 2014
Mike Kreidler
Insurance Commissioner
AMENDATORY SECTION (Amending WSR 13-15-025, filed 7/9/13, effective 7/10/13)
WAC 284-43-880 Pediatric vision services.
A health benefit plan must include "pediatric vision services" in its essential health benefits package. The base-benchmark plan covers pediatric services for the categories set forth in WAC 284-43-878 (1) through (9), but does not include pediatric vision services. Pediatric vision services are vision services delivered to enrollees under age nineteen.
(1) A health benefit plan must cover pediatric vision services as an embedded set of services.
(2) Supplementation: The state EHB-benchmark plan requirements for pediatric vision benefits must be offered at a substantially equal level and classified consistent with the designated supplemental base-benchmark plan for pediatric vision services, the Federal Employees Vision Plan with the largest enrollment and published by the U.S. Department of Health and Human Services at on July 2, 2012.
(a) The vision services included in the pediatric vision services category are:
(i) Routine vision screening; and
(ii) A comprehensive eye exam for children, including dilation as professionally indicated((,)) and with refraction every calendar year;
(((ii))) (iii) One pair of prescription lenses or contacts every calendar year, including polycarbonate lenses and scratch resistant coating. Lenses may include single vision, conventional lined bifocal or conventional lined trifocal, or lenticular lenses;
(((iii))) (iv) One pair of frames every calendar year. An issuer may establish networks or tiers of frames within their plan design as long as there is a base set of frames to choose from available without cost sharing;
(((iv))) (v) Contact lenses covered once every calendar year in lieu of the lenses and frame benefits. Issuers must apply this limitation based on the manner in which the lenses must be dispensed. If disposable lenses are prescribed, a sufficient number and amount for one calendar year's equivalent must be covered. The benefit includes the evaluation, fitting and follow-up care relating to contact lenses. If determined to be medically necessary, contact lenses must be covered in lieu of eyeglasses at a minimum for the treatment of the following conditions: Keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and irregular astigmatism;
(((v))) (vi) Low vision optical devices including low vision services, training and instruction to maximize remaining usable vision as follows:
(A) One comprehensive low vision evaluation every five years;
(B) High power spectacles, magnifiers and telescopes as medically necessary, with reasonable limitations permitted; and
(C) Follow-up care of four visits in any five year period, with prior approval.
(b) The pediatric vision supplemental base-benchmark specifically excludes, and issuer must not include in its actuarial value for the category:
(i) Visual therapy, which is otherwise covered under the medical/surgical benefits of the plan;
(ii) Two pairs of glasses may not be ordered in lieu of bifocals;
(iii) Medical treatment of eye disease or injury, which is otherwise covered under the medical/surgical benefits of the plan;
(iv) Nonprescription (Plano) lenses; and
(v) Prosthetic devices and services, which are otherwise covered under the rehabilitative and habilitative benefit category.