Chapter 5160-6 Vision Care Services

5160-6-01 Eligible vision care providers and vision co-payment provisions.

(A) Eligible providers of vision services.

(1) Ophthalmologists, optometrists, and opticians currently licensed under Chapters 4725. and 4731. of the Revised Code are eligible to participate in the medicaid program and may provide services within the scope of practice as established by Chapters 4725. and 4731. of the Revised Code. These services are identified in Chapter 5101:3-6 of the Administrative Code.

(2) A professional organization (group practice or partnership) of optometrists, ophthalmologists, and/or opticians is also considered an eligible provider if organized under Chapter 1785. of the Revised Code for the sole purpose of providing vision care services.

(3) Optical laboratories with whom the department has a current vision volume purchasing contract are eligible providers of frames and lenses.

(4) Medicaid reimbursement is contingent upon a valid provider agreement being in effect while services were provided in accordance with rule 5101:3-1-60 of the Administrative Code.

(5) Other eligible providers of vision services include, but are not limited to, the following medicaid providers if the providers employ or have under contractual arrangement individuals licensed to practice optometry:

(a) Fee-for-service ambulatory health care clinics as defined in Chapter 5101:3-13 of the Administrative Code.

(b) Outpatient health facilities as defined in Chapter 5101:3-29 of the Administrative Code.

(c) Rural health clinics as defined in Chapter 5101:3-16 of the Administrative Code.

(d) Federally qualified health centers as defined in Chapter 5101:3-28 of the Administrative Code.

(B) Co-payment (except for medicaid consumers enrolled in the medicaid managed health care program).

(1) For dates of service beginning on or after January 1, 2006, vision services are subject to medicaid co-payments in accordance with this rule and are subject to the provisions in accordance with rules 5101:3-1-09 and 5101:3-1-60 of the Administrative Code.

(2) The vision co-payments set forth in this rule apply to consumers who are eligible under the disability medical assistance (DMA) program in accordance with rule 5101:3-23-01 of the Administrative Code, when the vision services provided are covered under the DMA program in accordance with Chapter 5101:3-23 of the Administrative Code.

(3) The following exam codes are subject to a two dollar co-payment per date of service per claim:

(a) 92002 medical exam and evaluation: intermediate, new patient

(b) 92012 medical exam and evaluation; intermediate, established patient

(c) 92004 comprehensive, new patient, one or more visits

(d) 92014 comprehensive, established patient, one or more visits

(4) The following dispensing codes are subject to a one dollar co-payment per date of service per claim:

(a) 92340 fitting of spectacles, except for aphakia; monofocal

(b) 92341 fitting of bifocals, except for aphakia; monofocal

(c) 92342 fitting of multifocal, other than bifocal for aphakia; monofocal

Replaces: 5101:3-6-01

Effective: 01/01/2006
R.C. 119.032 review dates: 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0112
Rule Amplifies: 5111.01 , 5111.02 , 5111.0112 , Section 206.66.45 of Am. Sub. HB 66, 126th GA
Prior Effective Dates: 4/7/77, 12/21/77, 4/l/84, 5/9/86, 8/22/88 (Emer), 11/18/88, 7/1/02

5160-6-02 Scope of coverage.

(A) Ohio medicaid reimburses for covered vision services and ophthalmic materials included in appendix DD to rule 5101:3-1-60 of the Administrative Code and delivered by eligible providers to eligible consumers. The range of covered vision care professional services includes examinations, fittings, and dispensing of ophthalmic materials(including contact lenses, low vision aids, etc.).

(B) If a volume purchase contract(s) is not in effect, the cost of frames and lenses will be reimbursed to the provider.

(1) The standard frame for the vision care program is a moderately priced ZYL or metal frame. Discountined frames will not be reimbursed at original wholesale price.

(2) The following lenses are covered under the vision care program:

(a) Single-vision scratch resistant coated plastic and polycarbonate lenses.

(b) Bifocal scratch resistant coated plastic and polycarbonate.

(c) Aphakic single vision and multifocal lenses.

(d) Trifocals scratch resistant coated plastic and polycarbonate lenses.

(e) Additions for single and bifocal vision include: prism, industrial thickness, myodisc, cylinder> 6.25, special base curve, ultra-violet tint, slab-off lens, fresnel prism, frosted lens, tints, photochromatic, and high index plastic lenses, and engraved name on temple.

(f) Glass lenses will be covered with prior authorization (PA) when medically necessary.

(C) If the Ohio department of job and family services (ODJFS) has entered into a volume purchase contract(s) for the purchase of frames and lenses for Ohio medicaid patients:

(1) The covered frames and lenses shall be specified in the contract(s).

(2) Only those lenses specified in the contract(s) and supplied by the contractor(s) shall be covered unless the purchase of materials is prior-authorized by ODJFS.

(3) Only those frames specified in the contract(s) and supplied by the contractor(s) or frames covered under a previous contract(s) shall be covered unless the purchase of materials is prior authorized by ODJFS.

(4) The prices for materials under the contract shall be determined by competitive bid, or request for proposal.

(5) ODJFS will directly reimburse the optical laboratory for the contracted lenses and frames.

(6) All lenses and frames must be of acceptable quality and workmanship as determined by ODJFS.

(D) For covered materials not part of the vision volume purchase contract see rule 5101:3-6-11 of the Administrative Code.

(E) The following applies to vision services provided in an inpatient or outpatient hospital setting:

(1) Vision care exam and fitting services are covered and reimbursed in accordance with paragraph (D) of rule 5101:3-2-04 of the Administrative Code.

(2) Vision care materials are covered and reimbursed in accordance with paragraphs (B), (C), and (D) of this rule.

Effective: 03/05/2009
R.C. 119.032 review dates: 11/24/2008 and 03/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 9/19/77, 12/30/77, 4/1/84, 5/9/86, 5/1/87, 8/22/88 (Emer), 11/18/88, 7/1/93, 7/1/02, 1/1/06

5160-6-04 Vision care limitations.

(A) The following are limitations to comprehensive vision examinations:

(1) Each consumer age twenty-one and older but younger than age sixty is limited to one comprehensive vision examination and to one complete frame and pair of lenses per twenty-four-month period.

(2) Each consumer age twenty and younger or age sixty and older is limited to one comprehensive vision examination and to one complete frame and pair of lenses per twelve-month period.

(B) The following limitation applies to vision care services in long-term care facilities (LTCF): Vision care services provided in an LTCF must have a written request for examination or treatment signed by the consumer or responsible guardian that is retained by the billing provider. The attending physician may sign the request if the consumer is mentally unable to sign and the guardian is not available to sign the request for services.

(C) The following limitations apply to lens prescriptions:

(1) Lens prescriptions must be at least: + 0.75 sphere or - 0.50 sphere, 0.50 cylinder, 0.50 diopter imbalance, 1/2 prism diopter vertical, or 3 prism diopter lateral. These prescription minimums apply to new, duplications, and changes in a prescription.

(2) Lens prescription changes must still meet the lens prescription minimum requirements as stated in paragraph (C)(1) of this rule and must be at least: ± 0.50 sphere, ± 0.50 cylinder, 10 degrees for a 1.00 cylinder or less, or 5 degrees for a 1.12 cylinder or more.

(3) Lens coatings of any type are not separately reimbursable by the department.

(4) Lens edge polishing or any other cosmetic lens embellishment is not separately reimbursable by the department.

(5) Lenses prescribed to be used primarily as sunglasses that are prescribed in addition to regular prosthetic lenses are not reimbursable by the department unless a prior authorization is obtained for medical necessity.

(D) The following vision care items are covered if prior-authorized as set forth in rule 5101:3-1-31 of the Administrative Code:

(1) Contact lenses;

(2) Tinted lenses;

(3) Glass lenses;

(4) U-V lenses;

(5) Orthoptic or pleoptic training;

(6) Prosthetic eye;

(7) Any replacement of a complete set of eyeglasses prior to the expiration of the time limitations found in paragraph (A) of this rule;

(8) Photochromatic lenses;

(9) Low or subnormal vision aids; or

(10) Frames and lenses provided from a source other than the current vision volume purchase contract optical laboratory.

Effective: 03/05/2009
R.C. 119.032 review dates: 11/24/2008 and 03/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 9/19/77, 12/30/77, 4/1/84, 5/9/86, 5/1/87, 8/22/88 (Emer), 11/18/88, 7/1/02, 1/1/06

5160-6-07 Covered vision services.

(A) General ophthalmological services.

(1) A "comprehensive ophthalmological service" is a general evaluation of the complete visual system The service includes history, general medical observation, external and ophthalmoscopic examination, gross visual fields and basic sensorimotor examination. It can includes: biomicroscopy, examination with cycloplegia or mydriasis, tonometry and determination of refractive state. Comprehensive ophthalmological services always include initiation of diagnostic and treatment programs (e.g. prescription of lenses). In order to be reimbursed, providers must use the following procedure codes when rendering comprehensive ophthalmological services:

For dates of service beginning on and after April 1, 2004, to be reimbursed for comprehensive ophthalmologic services, bill the following codes:

(a) Code 92004 for a new consumer or code 92014 for an established consumer.

(b) If the individual receiving special ophthalmologic services is either twenty years of age or under or sixty years of age or older, codes 92004 and 92014 must be billed in conjunction with modifier UB, i.e., 92004UB.

(c) The UB modifier allows for a comprehensive ophthalmologic service once per year.

(2) An "intermediate ophthalmological service" is an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. An intermediate ophthalmological service includes history, general medical observation, external ocular and adnexal examination and other diagnostic procedures. The following procedure codes must be used in order to be reimbursed for rendering intermediate ophthalmological services.

(a) 92002 - New patient intermediate service; or

(b) 92012 - Established patient intermediate service.

(B) Other vision care services including covered ophthalmological/optometric diagnostic and treatment services:

(1) For the detection and/or treatment of ocular abnormalities that may be evidence of disease, pathology or injury, vision care providers may bill for services using the appropriate evaluation and management service level code (99XXX series) in accordance with the physicians' "Current Procedural Terminology (CPT)," code definitions and instructions as referenced in rule5101:3-1-60 of the Administrative Code. These services may be subject to review by the department to determine whether they are necessary to detect or treat, within the scope of the provider's license, ocular abnormalities that may be evidence of disease, pathology, or injury. These evaluation and management services codes may not be billed with the general ophthalmological service codes listed in paragraphs (A)(1) and (A)(2) of this rule.

(2) A "refractive service" is the medicaid-covered component of a comprehensive eye exam provided to a medicaid and medicare-covered consumer in conjunction with other medicare covered eye exam procedures. It is only reimbursed as a separate and distinct service by medicaid when medicare payment for an eye exam does not include payment for the refraction services component of the exam. Use code 92015 to bill for the refraction component of a medicare-covered exam. Code 92015 cannot be billed in conjunction with the general ophthalmological service codes listed in paragraphs (A)(1) and (A)(2) of this rule.

(3) "Special ophthalmological/optometric services", non-routine ophthalmoscopy and other specialized ophthalmological services are medicaid-covered and are reimbursable by billing the appropriate physicians' "Current Procedural Terminology (CPT)" code as referenced in rule5101:3-1-60 of the Administrative Code. These services are subject to review by the department to determine whether the service is necessary to detect or treat ocular abnormalities that may be evidence of disease, pathology

(4) Certain vision procedures listed under the "Special Ophthalmological Services," the "Ophthalmoscopy," and the "Other Specialized Services" section of the CPT have been identified as diagnostic and therapeutic procedures which are composed of professional and technical components. These services are specifically identified, must be billed, and shall be reimbursed in accordance with rule5101:3-4-11 of the Administrative Code.

Effective: 01/01/2006
R.C. 119.032 review dates: 09/29/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 5/9/86, 8/1/86, 8/22/88 (Emer), 11/18/88, 7/1/93, 7/1/94, 7/1/02, 4/1/04

5160-6-11 Covered services and materials not purchased under the vision volume purchase contract.

(A) Low or subnormal vision aids: low vision aids are not purchased under the volume purchase contract. All low or subnormal vision aids require prior authorization and must be ordered from an optical laboratory of the provider's choice. To be reimbursed for low vision aids, the provider must use the appropriate healthcare common procedure coding system (HCPCS) level codes as follows:

(1) V2600 - Hand-held low vision aid and any other non-spectacle mounted aid;

(2) V2610 - Single-lens spectacle mounted low vision aid; or

(3) V2615 - Telescopic and other compound lens systems including: distance vision telescope, near vision telescopes, or compound lens systems.

(B) Ocular prostheses and prostheses services: Ocular prostheses and prostheses services require prior authorization and are not purchased under the volume purchase contract. To be reimbursed for ocular prostheses, the provider must use the appropriate HCPCS level codes as follows:

(1) V2623 - Prosthetic eye, plastic, custom;

(2) V2624 - Polishing/resurfacing of ocular prosthesis;

(3) V2625 - Enlargement of ocular prosthesis;

(4) V2626 - Reduction of ocular prosthesis;

(5) V2627 - Scleral cover shell;

(6) V2628 - Fabrication and fitting of ocular conformer; or

(7) V2629 - Prosthetic eye, other type.

(C) Contact lenses and contact lens services.

(1) Contact lenses and contact lens services are covered when prior-authorized by the Ohio department of job and family services (ODJFS). The department will authorize contact lenses under the following conditions:

(a) To correct aphakia.

(b) To correct high refractive errors, greater than ten diopters, when the visual acuity cannot be corrected to 20/70 in the better eye with spectacle lenses and there is a significant improvement in visual acuity with contact lenses.

(c) There is a high degree of anisometriopta where binocularity can be substantiated.

(d) To treat keratoconus, where there is a high corneal astigmatism or corneal irregularities when the visual acuity cannot be corrected to 20/70 in the better eye with spectacles and there is a significant improvement with contact lenses.

(2) Contact lenses are not purchased under the vision volume purchase contract. All contact lenses must be prior-authorized and then ordered from an optical laboratory of the provider's choice. The following codes are per lens and must be reported twice when the code is appropriate for both eyes. To be reimbursed for contact lenses, use the appropriate HCPCS level codes as follows:

(a) V2500 - Contact lens, PMMA, spherical, per lens;

(b) V2501 - Contact lens, PMMA, toric or prism ballast, per lens;

(c) V2510 - Contact lens, gas permeable, spherical, per lens;

(d) V2511 - Contact lens, gas permeable, toric, prism ballast, per lens;

(e) V2513 - Contact lens, gas permeable, extended wear, per lens;

(f) V2520 - Contact lens, hydrophilic, spherical, per lens;

(g) V2521 - Contact lens, hydrophilic, toric, or prism ballast, per lens;

(h) V2523 - Contact lens, hydrophilic, extended wear, per lens;

(i) V2530 - Contact lens, scleral, gas impermeable, per lens; or

(j) V2599 - Contact lens, other type.

(3) Contact lens services are reimbursable by billing the appropriate physicians' "Current Procedural Terminology (CPT)" code as referenced in rule 5101:3-1-60 of the Administrative Code. Contact lens services must be prior-authorized byODJFS.

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 5/9/88, 8/22/88 (Emer), 11/18/88, 7/1/93, 12/31/96 (Emer), 3/22/97, 7/1/02, 12/30/05 (Emer), 3/27/06

5160-6-12 Spectacle fitting services.

(A) Spectacle fitting services are covered by medicaid. The consumer must be eligible at the time the fitting was initiated. If the exam and the fitting are performed by the same provider, the date of the exam may be considered the date the fitting was initiated. To be reimbursed for spectacle services, the provider must use the appropriate physicians' "Current Procedural Terminology (CPT)" code as referenced in rule5101:3-1-60 of the Administrative Code as listed in paragraphs (A)(1) to (A)(8) of this rule.

(1) 92340 - Monofocal, except for aphakia.

(2) 92341 - Bifocal, except for aphakia.

(3) 92342 - Multifocal, other than bifocal, except for aphakia.

(4) 92352 - Fitting of spectacle prosthesis for aphakia; monofocal.

(5) 92353 - Fitting of spectacle prosthesis for aphakia; multifocal.

(6) 92354 - Fitting of spectacle-mounted low-vision aid; monofocal.

(7) 92355 - Fitting of spectacle-mounted low-vision aid; telescopic or other compound lens system.

(8) 92358 - Prosthesis service for aphakia, temporary.

(B) Spectacle fitting services for less than a complete pair of spectacles, must be reported as a reduced service by using the modifier 52 following the procedure code. These services will be reimbursed at one-half the full service rate.

Effective: 01/01/2006
R.C. 119.032 review dates: 09/29/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 7/22/86, 8/1/86, 8/22/88 (Emer), 11/18/88, 7/1/93, 7/1/02