MARCH Vision Care. Utah Specific Information. Table of Contents

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1 This document contains information specific to the State of Utah. Please refer to the Provider Reference Guide for general information regarding plan administration. Table of Contents 1.1 Covered s - Molina Healthcare of Utah Child Health Insurance Program (CHIP) Plan B, C & D (Medicaid) Covered s - Molina Healthcare of Utah Non-Traditional Plan (Medicaid) Covered s - Molina Healthcare of Utah Traditional Plan (Medicaid) Covered s - Molina Healthcare of Utah Options Plus (Medicare) Plan Covered s - Molina Healthcare of Utah Healthy Advantage (Medicare) Plan Covered s - Molina Healthcare of Utah Options (Medicare) Plan Revised November 28, 2017 Page 1 of 8

2 1.1 Covered s - Molina Healthcare of Utah Child Health Insurance Program (CHIP) Plan B, C & D (Medicaid) Limitations/Criteria Exam Standard - 1 service date every year. Plan B - $5 copay, 1 service date every year. Plan C - $25 copay, 1 service date every year. Plan D - 1 service date every year. Non-Covered Services Eyewear. Refraction. Medical or surgical eye care. 1.2 Covered s - Molina Healthcare of Utah Non-Traditional Plan (Medicaid) Limitations/Criteria Exam 1 service date every year up to $30. Member is responsible for charges exceeding $30. $0 copay when services are performed by a licensed optometrist. $3 copay for CHEC members and pregnant women when services are performed by a licensed ophthalmologist. $0 copay for American Indians and Alaska Natives when services are performed by a licensed ophthalmologist Frame 1 unit every 2 years for CHEC members. Frame must be selected from the MARCH frame kit. Deluxe Frame 1 unit, 10% discount, $10 allowance,every 2 years for CHEC members. Members may waive the standard frame selection and opt for any frame shown at the provider s location. The member receives a $10 allowance and the provider may bill the member for the balance with the following four conditions being met: Provider has an established policy for billing all Medicaid members for services not covered by a third party. (The charge cannot only be billed to Medicaid members.) The member is advised prior to receiving a non-covered service that Medicaid will not pay for the service. The member agrees to be personally responsible for the payment. The agreement is made in writing between the provider and the member which details the service and the amount to be paid by the member. To identify deluxe frames, please bill using HCPCS code V2025. Frame Replacement 1 unit every 2 years for CHEC members. Frame may be replaced more frequently when one of the following criterion is met: Revised November 28, 2017 Page 2 of 8

3 Deluxe Frame Replacement Limitations/Criteria To identify replacement frames, please bill using modifier code RA. Frame must be selected from the MARCH frame kit. 1 unit, 10% discount, $10 allowance,every 2 years for CHEC members. Members may waive the standard frame selection and opt for any frame shown at the provider s location. The member receives a $10 allowance and the provider may bill the member for the balance with the following four conditions being met: Provider has an established policy for billing all Medicaid members for services not covered by a third party. (The charge cannot only be billed to Medicaid members.) The member is advised prior to receiving a non-covered service that medicaid will not pay for the service. The member agrees to be personally responsible for the payment. The agreement is made in writing between the provider and the member which details the service and the amount to be paid by the member. Frame may be replaced more frequently when one of the following criterion is met: To identify deluxe replacement frames, please bill using HCPCS code V2025 and modifier code RA. 2 units every 2 years CHEC members. Lenses must be provided by the MARCH lab. Please refer to Exhibit D in the Provider Reference Guide for lab information. Lenses (Single, Bifocal and Trifocal) Lens Replacement 2 units every 2 years CHEC members. If lenses alone need replacing, the provider must use existing frames. Eyeglasses may be replaced more frequently when one of the following criterion is met: To identify replacement frames, please bill using modifier code RA. Lenses must be provided by the MARCH lab. Please refer to Exhibit D in the Provider Reference Guide for lab information. Contact Lenses 2 units every 2 years for CHEC members. Covered when: Visual acuity cannot be corrected to 20/70 in the better eye with spectacle lenses. Revised November 28, 2017 Page 3 of 8

4 Limitations/Criteria The refractive error is greater than +/ diopters. An unusual eye disease or disorder exists which is not correctable with eyeglasses. To correct aphakia, keratoconus, nystagmus, or severe corneal distortion. Other special medical conditions which medically require contacts. Fitting contact lenses includes determining correction measurements, writing the prescription, fitting and follow-up care necessary for proper wear of the contact lens. Additional office visits for any of these services will not be reimbursed. Soft contact lenses may be approved when medically necessary because of a condition described above and either circumstance below: Soft lenses are prescribed by an ophthalmologist or optometrist as a bandage to treat eye disease or injury Soft lenses are prescribed for a member who is unable to wear hard contacts due to the shape or surface of the eye and who is unable to obtain the necessary correction with eyeglasses Gas permeable contact lenses may be provided when a specific medical need exists which precludes the use of eyeglasses. Repairs Repair of a damaged lens or frame is covered as needed. Repairs due to member neglect or abuse are NOT covered. Non-Covered Services. Medical or surgical eye care. Revised November 28, 2017 Page 4 of 8

5 1.3 Covered s - Molina Healthcare of Utah Traditional Plan (Medicaid) Limitations/Criteria Exam 1 service date every year. $0 copay when services are performed by a licensed optometrist. $3 copay for CHEC members and pregnant women when services are performed by a licensed ophthalmologist. $0 copay for American Indians and Alaska Natives when services are performed by a licensed ophthalmologist Frame 1 unit every 2 years for CHEC members and pregnant women. $3 copay ages Frame must be selected from the MARCH frame kit. Deluxe Frame 1 unit, 10% discount, $10 allowance,every 2 years for CHEC members or pregnant women. Members may waive the standard frame selection and opt for any frame shown at the provider s location. The member receives a $10 allowance and the provider may bill the member for the balance with the following four conditions being met: Provider has an established policy for billing all Medicaid members for services not covered by a third party. (The charge cannot only be billed to Medicaid members.) The member is advised prior to receiving a non-covered service that medicaid will not pay for the service. The member agrees to be personally responsible for the payment. The agreement is made in writing between the provider and the member which details the service and the amount to be paid by the member. To identify deluxe frames, please bill using HCPCS code V2025. Frame Replacement 1 unit every 2 years for CHEC members and pregnant women. Frame may be replaced more frequently when one of the following criterion is met: To identify replacement frames, please bill using modifier code RA. Frame must be selected from the MARCH frame kit. Deluxe Frame 1 unit, 10% discount, $10 allowance,every 2 years for CHEC members and pregnant women. Replacement Members may waive the standard frame selection and opt for any frame shown at the provider s location. The member receives a $10 allowance and the provider may bill the member for the balance with the following four conditions being met: Provider has an established policy for billing all Medicaid members for services not covered by a third party. (The charge cannot only be billed to Medicaid members.) The member is advised prior to receiving a non-covered service that medicaid will not pay for the service. The member agrees to be personally responsible for the payment. The agreement is made in writing between the provider and the member which details the service and the amount to be paid by the member. Frame may be replaced more frequently when one of the following criterion is met: Revised November 28, 2017 Page 5 of 8

6 Limitations/Criteria To identify deluxe replacement frames, please bill using HCPCS code V2025 and modifier code RA. Lenses (Single, Bifocal 2 units every 2 years CHEC members and pregnant women. and Trifocal) Lenses must be provided by the MARCH lab. Please refer to Exhibit D in the Provider Reference Guide for lab information. Lens Replacement 2 units every 2 years CHEC members and pregnant women. If lenses alone need replacing, the provider must use existing frames. Eyeglasses may be replaced more frequently when one of the following criterion is met: To identify replacement frames, please bill using modifier code RA. Lenses must be provided by the MARCH lab. Please refer to Exhibit D in the Provider Reference Guide for lab information. Contact Lenses 2 units every 2 years for CHEC members and pregnant women. Covered when: Visual acuity cannot be corrected to 20/70 in the better eye with spectacle lenses. The refractive error is greater than +/ diopters. An unusual eye disease or disorder exists which is not correctable with eyeglasses. To correct aphakia, keratoconus, nystagmus, or severe corneal distortion. Other special medical conditions which medically require contacts. Fitting contact lenses includes determining correction measurements, writing the prescription, fitting and follow-up care necessary for proper wear of the contact lens. Additional office visits for any of these services will not be reimbursed. Soft contact lenses may be approved when medically necessary because of a condition described above and either circumstance below: Soft lenses are prescribed by an ophthalmologist or optometrist as a bandage to treat eye disease or injury Soft lenses are prescribed for a member who is unable to wear hard contacts due to the shape or surface of the eye and who is unable to obtain the necessary correction with eyeglasses Gas permeable contact lenses may be provided when a specific medical need exists which precludes the use of eyeglasses. Repairs Repair of a damaged lens or frame is covered as needed. Revised November 28, 2017 Page 6 of 8

7 Limitations/Criteria Repairs due to member neglect or abuse are NOT covered. Non-Covered Services Medical or surgical eye care. 1.4 Covered s - Molina Healthcare of Utah Options Plus (Medicare) Plan 001 Limitations/Criteria Exam 1 service date every calendar year. Eyewear $150 allowance every calendar year. Allowance may be used toward frames, lenses, lens extras and/or contact lenses. Frame and lenses MUST be supplied by the provider. Contact lens fitting/examination/evaluation is deducted from the allowance. Eyewear After Cataract Surgery One pair of eyeglasses (standard frame and lenses) OR one pair of contact lenses following cataract surgery with an intraocular lens. Allowance does not apply. To identify eyewear after cataract surgery, please bill with the appropriate diagnosis code for cataract surgery. Glaucoma Screening 1 service date every calendar year when member is considered at-risk according to the following Medicare definitions of at-risk : Individuals with a family history of glaucoma. Individuals with diabetes mellitus. African-Americans ages 50 and older. Hispanic-Americans ages 65 and older. Non-Covered Services Medical or surgical eye care. 1.5 Covered s - Molina Healthcare of Utah Healthy Advantage (Medicare) Plan 006 Limitations/Criteria Exam 1 service date every calendar year. Eyewear $150 allowance every calendar year. Allowance may be used toward frames, lenses, lens extras and/or contact lenses. Frame and lenses MUST be supplied by the provider. Contact lens fitting/examination/evaluation is deducted from the allowance. Eyewear After Cataract Surgery One pair of eyeglasses (standard frame and lenses) OR one pair of contact lenses following cataract surgery with an intraocular lens. Allowance does not apply. To identify eyewear after cataract surgery, please bill with the appropriate diagnosis code for cataract surgery. Glaucoma Screening 1 service date every calendar year when member is considered at-risk according to the following Medicare definitions of at-risk : Individuals with a family history of glaucoma. Individuals with diabetes mellitus. African-Americans ages 50 and older. Hispanic-Americans ages 65 and older. Non-Covered Services Medical or surgical eye care. Revised November 28, 2017 Page 7 of 8

8 1.6 Covered s - Molina Healthcare of Utah Options (Medicare) Plan 007 Limitations/Criteria Exam 1 service date every calendar year. Eyewear $200 allowance every 2 calendar years. Allowance may be used toward frames, lenses, lens extras and/or contact lenses. Frame and lenses MUST be supplied by the provider. Contact lens fitting/examination/evaluation is deducted from the allowance. Eyewear After Cataract Surgery One pair of eyeglasses (standard frame and lenses) OR one pair of contact lenses following cataract surgery with an intraocular lens. Allowance does not apply. To identify eyewear after cataract surgery, please bill with the appropriate diagnosis code for cataract surgery. Glaucoma Screening 1 service date every calendar year when member is considered at-risk according to the following Medicare definitions of at-risk : Individuals with a family history of glaucoma. Individuals with diabetes mellitus. African-Americans ages 50 and older. Hispanic-Americans ages 65 and older. Non-Covered Services Medical or surgical eye care. Revised November 28, 2017 Page 8 of 8

MARCH Vision Care. Missouri Specific Information. Table of Contents

MARCH Vision Care. Missouri Specific Information. Table of Contents This document contains information specific to the State of Missouri. Please refer to the Provider Reference Guide for general information regarding plan administration. Table of Contents 1.1 Covered s