Rules of Department of Social Services Division 70—MO HealthNet Division Chapter 40—Optical Program

Title Page

13 CSR 70-40.010 Optical Benefits and Limitations—MO HealthNet Program...... 3

JOHN R. ASHCROFT (9/30/21) CODE OF STATE REGULATIONS 1 Secretary of State Chapter 40—Optical Program 13 CSR 70-40

Title 13—DEPARTMENT OF specified for his/her profession as follows: (E) Temple. SOCIAL SERVICES (A) An optometrist must be a duly licensed (F) Lenses, single vision. Division 70—MO HealthNet Division Doctor of (OD) to participate in (G) Lenses, bifocal. Chapter 40—Optical Program the MO HealthNet program, must be licensed (H) Lenses, trifocal. in accordance with the licensing provisions of (I) Lenses, cataract. 13 CSR 70-40.010 Optical Benefits and the state in which s/he practices, and must (J) Special frames. Limitations—MO HealthNet Program have a current MO HealthNet participation (K) Special lenses. agreement and provider number; (L) Miscellaneous repairs. PURPOSE: This rule establishes the basis for (B) A physician must be a duly licensed (M) Scleral cover shell, stock, or custom. administering the Optical Program under the Doctor of Medicine (MD) or Doctor of (N) Prosthetic eye, plastic, or custom. MO HealthNet program, including the desig- Osteopathy (DO) to participate in the MO (O) Prosthetic eye, refitting. nation of professional persons who may per- HealthNet program, must be licensed in (P) Prosthetic eye check/polishing/cleaning. form optical services; services which are cov- accordance with the licensing provisions of (Q) Rose I and Rose II tints. ered, noncovered, and limitations within the the state in which s/he practices, and must (R) Photochromatic lenses. program; and the method of reimbursement. have a current MO HealthNet participation (S) Orthoptic and/or pleoptic training, with agreement and provider number; continuing optometric direction and evalua- PUBLISHER’S NOTE: The secretary of state (C) A clinic can participate in the Optical tion (visual therapy/training). has determined that the publication of the Program if it has a current MO HealthNet (T) Fitting of for treatment of entire text of the material which is incorpo- Program clinic number. In addition to the disease, including supply of lens (therapeutic rated by reference as a portion of this rule clinic number, each of the performing bandage lens). would be unduly cumbersome or expensive. optometrists must have an effective participa- (U) Visual field examination with optomet- This material as incorporated by reference in tion agreement and MO HealthNet program ric diagnostic evaluation; tangent screen, this rule shall be maintained by the agency at provider number. Reimbursement may be autoplot, or equivalent. its headquarters and shall be made available made to the clinic for all covered services (V) Electro-oculography, with medical to the public for inspection and copying at no provided at the clinic; and diagnostic evaluation. more than the actual cost of reproduction. (D) An , optical dispenser, or man- (W) Visually evoked potential (response) This note applies only to the reference mate- ufacturer of prosthetic eyes must have a cur- study, with medical diagnostic evaluation. rial. The entire text of the rule is printed rent MO HealthNet participation agreement (X) Quantitative perimetry, for example, here. and provider number. several isopters on Goldmann perimeter or equivalent. (1) Administration. The Department of Social (4) Types of Service Reimbursed by the MO (Y) Static and kinetic perimetry or equiva- Services, MO HealthNet Division shall HealthNet Program for Each Profession. lent. administer the Optical Program. The Depart- (A) Optometrist or Clinic. (Z) Serial tonometry with optometric diag- ment of Social Services, MO HealthNet Divi- 1. Eye examinations. nostic evaluation (separate procedure), one sion shall determine, and include in the Opti- 2. Refractions. (1) or more sessions, same day. cal Provider manual, the optical services 3. Eyeglasses. (AA) Tonography with optometric diag- covered and not covered, the program limita- 4. Prosthetic eyes. nostic evaluation, recording indentation tions, and the maximum allowable fees for all 5. Special ophthalmological services. tonometer method or perilimbal suction covered services. The Optical Provider man- (B) or Optical Dispensers. method. ual is incorporated by reference and made a 1. Eyeglasses. (BB) Color vision examination, extended, part of this rule as published by the Depart- 2. Prosthetic eyes. for example, anomaloscope or equivalent. ment of Social Services, MO HealthNet Divi- (C) Manufacturers of Prosthetic Eyes— (CC) Dark adaptation examination, with sion, 615 Howerton Court, Jefferson City, Prosthetic Eyes. optometric diagnostic evaluation. MO 65109, at its website at (D) Physicians (MD or DO). http://manuals.momed.com/collections/col- 1. Eye examinations. (7) Program Limitations. lection_opt/print.pdf November 24, 2020. 2. Refractions. (A) Optical Program services require pre- This rule does not incorporate any subse- 3. Eyeglasses (Must be enrolled as an certification. Pre-certification serves as a uti- quent amendment or additions. Services cov- Optical provider). lization management tool, allowing payment ered shall include only those which are clear- 4. Prosthetic eyes (Must be enrolled as for services that are medically necessary, ly shown to be medically necessary. an Optical provider). appropriate, and cost effective without com- 5. Special ophthalmological services. promising the quality of care to participants. (2) Participants Eligible. Any participant who An enrolled optical provider must initiate is eligible for MO HealthNet benefits as (5) Reimbursement. MO HealthNet reimburse- requests for pre-certification and MO Health- determined by the Family Support Division ment will be the lower of the provider’s usual Net must issue approval before delivery of and who is found to be in need of optical ser- and customary charge to the general public or service. The pre-certification medical criteria vices as described in this regulation subject to the MO HealthNet allowable amount. can be found in the Optical Provider Manual the limitations set forth in subsections identified in section (1) of this rule. (7)(A)–(X). (6) Covered Services. (B) One (1) comprehensive or one (1) lim- (A) Complete or limited . ited eye examination is allowed per two (2) (3) Provider Participation. To be eligible for (B) Eye refraction. years (within a twenty-four- (24-) month peri- participation in the MO HealthNet Optical (C) Eyeglasses. od of time) under the MO HealthNet pro- Program, a provider must meet the criteria (D) Frames. gram. Eligible children, pregnant women,

JOHN R. ASHCROFT (9/30/21) CODE OF STATE REGULATIONS 3 Secretary of State 13 CSR 70-40—DEPARTMENT OF SOCIAL SERVICES Division 70—MO HealthNet Division

individuals residing in a nursing home, and 4.00 diopters for one (1) eye or plus or minus 1. Child age twenty (20) and under who blind persons are allowed one (1) comprehen- 4.00 diopters for each eye, cataract lenses, or requires for school performances; sive or one (1) limited eye examination per special bifocal lenses (for example, plastic 2. Visual acuity 20/40 or less; or year (within a twelve- (12-) month period of Executive lenses). 3. Protective eyewear for participants time) under the MO HealthNet program. Pay- (J) Plastic lenses may be dispensed under with sight in only one (1) eye. ment for a comprehensive eye examination the MO HealthNet program. Reimbursement (R) Any warranties extended by optical will be made only if six (6) or more of the will be at the same rate as comparable glass companies for optical materials to private-pay following procedures have been performed: lenses. Additional payment will be allowed patients must also apply to those same mate- 1. Refraction far point and near point; for plastic lenses that meet the definition of rials dispensed to MO HealthNet partici- 2. Case history; special lenses and are medically justified. pants. 3. Visual acuity testing; (K) Photochromatic lenses are covered (S) The MO HealthNet program allows 4. External eye examination; only if medically necessary. one (1) prosthetic eye per eye (one (1) left 5. Pupillary reflexes; (L) Tinted lenses (Rose I and Rose II) are and one (1) right) within a five- (5-) year 6. Ophthalmoscopy; covered if medically necessary. period. If the prosthetic eye is lost, 7. Ocular motility testing; (M) Replacement of optical materials and destroyed, cracked, or deteriorated, payment 8. Binocular coordination; repairs in excess of program limitations may will be allowed for replacement. 9. Vision fields; be covered if medically necessary, or (T) Optometrists may be reimbursed for 10. Biomicroscopy (slit lamp); required for employment training, or educa- visual therapy training when there is a prog- 11. Tonometry; tional purposes, as follows: nosis for substantial improvement or correc- 12. Color vision; and 1. Replacement of complete eyeglasses tion of an ocular or vision condition. These 13. Depth perception. (frames and lenses). conditions include amblyopia, eccentric (non- (C) If fewer than six (6) of these are per- A. Lenses and frames broken (partic- foveal) monocular fixation, suppression, formed, a limited examination must be billed. ipant must show provider the broken glasses inadequate motor or sensory fusion, and stra- (D) Eligible children, pregnant women, or the MO HealthNet program will not pay bismus (squint). The number of training ses- individuals residing in a nursing home, and for the glasses). sions is limited to one (1) per day, two (2) per blind persons may be allowed additional eye B. Lost. week, and a maximum of twenty (20) ses- examinations during the year (within a C. Destroyed. sions. If the patient shows significant twelve- (12-) month period of time) if medi- D. Stolen. improvement after the initial twenty (20) ses- cally necessary (that is, cataract examination, E. Repair of existing glasses would sions and the optometrist feels that further prescription change of 0.50 diopters or exceed the MO HealthNet allowable amount progress could be made, additional training greater). for new frames and lenses; sessions not to exceed a total of forty (40) (E) Eyeglasses are covered by the MO 2. Lenses—if medically necessary. sessions may be provided. HealthNet program for MO HealthNet eligi- A. Scratched. (U) Fitting of contact lens for treatment of ble participants when the prescription is at B. Broken. disease, including supply of lens (therapeutic least 0.75 diopters for one (1) eye or 0.75 C. Prescription change of at least bandage lens) is covered if it is prescribed by diopters for each eye. 0.50 diopters or greater; or a physician (MD or DO) or optometrist (OD) (F) Only one (1) pair of eyeglasses is 3. Frames—Temples, fronts, or both as a bandage to cover a diseased condition of allowed every two (2) years (within any twen- broken and repair would exceed the MO the eye, such as a bandage over an abrasion ty-four- (24-) month period of time) for MO HealthNet allowable amount for new frames. of the skin. The lens must be plain with no HealthNet eligible participants. (N) Repair of frames or replacement of corrective power. Diagnosis for which the (G) The original eyeglass prescription and parts of frames (temples) are covered as fol- lens should be reimbursed are Bullous Kero- laboratory invoices listing costs for optical lows: topathy, Corneal Ulcers, Ocular Pemphigoid, materials, lenses, and/or frames provided; 1. The cost of the repairs do not exceed and other corneal exposure problems. and the charge for grinding, edging, or the MO HealthNet allowable amount for new (V) Visual field examination with optomet- assembling of glasses must be kept on file by frames; and ric diagnosis evaluation, tangent screen auto- the provider for six (6) years and furnished to 2. Repair would provide a serviceable plot, or equivalent is covered when per- the MO HealthNet Division or its representa- frame for the participant. formed by an optometrist. tive upon request. (O) Temples may never be billed in addi- (W) Quantitative perimetry, for example, (H) Special frames are covered under the tion to complete new eyeglasses and new several isopters on Goldmann perimeter, or MO HealthNet program if they are required frames. equivalent is covered. for medical reasons. Special frames may be (P) An eye refraction may be reimbursed in (X) Serial tonometry with optometric diag- authorized if the patient requires special lens- addition to a comprehensive or limited eye nostic evaluation (separate procedure), one es (plus or minus 4.00 diopters for one (1) examination. Because an eye refraction is not (1) or more sessions on the same day is cov- eye or plus or minus 4.00 diopters for each covered by Medicare but is covered by MO ered when performed by an optometrist. Rou- eye and are extra thick or heavy), the struc- HealthNet, providers may bill MO HealthNet tine tonometry is included in the reimburse- ture of the patient’s face requires special for an eye refraction when the patient has ment for a comprehensive examination and frames (a very large face, wide-set eyes), or Medicare and MO HealthNet coverage. cannot be billed separately. the patient needs glasses with pads because of (Q) Eyeglasses may be covered by MO nose surgery. HealthNet for a prescription of less than 0.75 (8) Noncovered Services. (I) Special lenses are covered under the diopters if medically necessary. Eyeglasses (A) Eyeglass frames with hearing aids MO HealthNet program if they are medically less than 0.75 diopters will be approved for attached. justified and the prescription is plus or minus the following reasons: (B) Optical services or materials provided

4 CODE OF STATE REGULATIONS (9/30/21) JOHN R. ASHCROFT Secretary of State Chapter 40—Optical Program 13 CSR 70-40

to a participant who was not eligible on the 208.152, RSMo Supp. 2021.* This rule was date the service was provided or the optical previously filed as 13 CSR 40-81.170. Emer- materials were delivered to the patient. gency rule filed April 10, 1981, effective April (C) Sales or use tax on optical materials 20, 1981, expired July 10, 1981. Original rule (the participant is not responsible for and may filed April 10, 1981, effective July 11, 1981. not be billed for such taxes). Emergency amendment filed June 27, 2002, (D) Contact lenses other than for medical effective July 7, 2002, terminated Feb. 23, purposes as described above in subsection 2003. Amended: Filed July 15, 2002, effec- (7)(T). tive Feb. 28, 2003. Amended: Filed March 3, (E) Sunglasses. 2003, effective Oct. 30, 2003. Emergency (F) Lenses exceeding 65 mm in diameter amendment filed Aug. 11, 2005, effective or frames for such lenses. Sept. 1, 2005, expired Feb. 27, 2006. Amend- (G) Temporary lenses for cataract lenses. ed: Filed June 1, 2005, effective Nov. 30, (H) Eyeglass cases. 2005. Emergency amendment filed June 15, (I) Monicals. 2006 effective July 1, 2006, expired Dec. 28, (J) Magnifiers. 2006. Amended: Filed May 15, 2006, effec- (K) Eye medications. tive Nov. 30, 2006. Amended: Filed Aug. 17, (L) Repair of old frames if the repair 2009, effective Feb. 28, 2010. Amended: Filed exceeds the cost of new frames. Oct. 10, 2013, effective April 30, 2014. (M) Replacement of optical materials Amended: Filed March 5, 2021, effective Oct. resulting from patient abuse. 30, 2021. (N) Optical materials which are not medi- cally necessary. *Original authority: 208.152, RSMo 1967, amended (O) Nose pads. 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, (P) Eyeglass adjustments. 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo (Q) Optical materials not meeting MO 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, HealthNet Division standards. 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995. (R) Lenses or frames supplied incorrectly to the provider by the supplier or manufactur- er. (S) Replacement of lenses, complete eye- glasses, frames, or prosthetic eyes supplied incorrectly to participant by optical provider. (T) Optical materials in excess of those authorized within the benefit period.

(9) General Regulations. This rule shall not encompass all of the general regulations of the MO HealthNet program. These regula- tions, however, shall be in effect for the opti- cal section of the overall program.

(10) Records Retention. MO HealthNet may impose sanctions against a provider for fail- ure to make available or disclose to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO Health- Net records, in compliance with 13 CSR 70- 3.030. Providers must retain these records for six (6) years from the date of service. Fis- cal and medical records must coincide with, and fully document, services billed to the MO HealthNet agency. Providers must fur- nish or make the records available for inspec- tion or audit by the Department of Social Ser- vices or its representative upon request.

AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section

JOHN R. ASHCROFT (9/30/21) CODE OF STATE REGULATIONS 5 Secretary of State