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