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