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