MARCH Vision Care. South Carolina Specific Information. Table of Contents

Transcription

1 This document contains information specific to the State of South Carolina. Please refer to the Provider Reference Guide for general information regarding plan administration. Table of Contents 1.1 Covered s - Molina Healthcare of South Carolina (Medicaid) Covered s - Molina Healthcare of South Carolina (MMP) Covered s - WellCare of South Carolina (Medicaid) Molina Healthcare of South Carolina MMP Reimbursement Procedures... 5 Revised June 24, 2015 Page 1 of 5

2 1.1 Covered s Molina Healthcare of South Carolina (Medicaid) Exam 1 service date every year. Exam Replacement Covered as needed ages 20 and under when one of the following criterion is met: The member is unable to return to or obtain the prescription from the previous provider AND criteria for replacement frame or lenses are met. A replacement exam is necessary to determine medical necessity for replacement frame or lenses. Necessary Medical Covered as needed when services are performed by an optometrist and are within the scope of licensure. Services Frame 1 unit every year ages 20 and under. 1 unit every 2 years ages 21 and older. Frame Replacement Covered as needed ages 20 and under if one of the following criterion is met: The most recent pair of eyeglasses was lost or destroyed for reasons beyond control of the recipient. Lens (Single, Bifocal, Trifocal, Polycarbonate) 2 units (1 pair) every year ages 20 and under. 2 units (1 pair) every 2 years ages 21 and older. Lens Replacement Covered as needed ages 20 and under if one of the following criterion is met: The most recent pair of eyeglasses was lost or destroyed for reasons beyond the control of the recipient. Necessary Contact Lenses Necessary Contact Lens Replacement Non-Covered Services Surgical eye care. 2 units (1 unit per eye) every year ages 20 and under in lieu of frame and lenses. 2 units (1 unit per eye) every 2 years ages 21 and older in lieu of frame and lenses. One of the following criterion must be met: A diagnosis of aphakia A diagnosis of monocular aphakia 2 units (1 unit per eye) every year ages 20 and under if the following criterion is met: The most recent pair of contact lenses was lost or destroyed for reasons beyond the control of the recipient, AND The member has one of the following diagnoses: Aphakia Monocular aphakia Revised June 24, 2015 Page 2 of 5

3 1.2 Covered s Molina Healthcare of South Carolina - MMP (Medicaid/Medicare) Exam 1 service date every year. Eyewear $150 allowance every 2 years In-house frame and lenses MUST be used. Allowance may be used toward frames, lenses and/or lens extras. Eyewear After Cataract Surgery One pair of eyeglasses (standard frame and lenses) or contact lenses after each cataract surgery with the insertion of 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 year when member is considered at-risk according to the following Medicare definitions of at-risk : Individuals with family history of glaucoma Individuals with diabetes mellitus African-Americans and ages 50 and older Hispanic-Americans and ages 65 and older Non-Covered Services Medical services. Low vision aids Vision therapy Revised June 24, 2015 Page 3 of 5

4 1.3 Covered s - WellCare of South Carolina (Medicaid) Exam 1 service date every year ages 20 and under. 1 service date every year for diabetic members ages 21 and older. Exam Replacement Covered as needed ages 20 and under when one of the following criterion is met: The member is unable to return to or obtain the prescription from the previous provider AND criteria for replacement frame or lenses are met. A replacement exam is necessary to determine medical necessity for replacement frame or lenses. Necessary Medical Covered as needed when services are performed by an optometrist and are within the scope of licensure. Services Frame 1 unit every year ages 20 and under. Frame Replacement Covered as needed ages 20 and under if one of the following criterion is met: The most recent pair of eyeglasses was lost or destroyed for reasons beyond control of the recipient. Lens (Single, Bifocal, 2 units (1 pair) every year ages 20 and under. Trifocal, Polycarbonate) Lens Replacement Covered as needed ages 20 and under if one of the following criterion is met: The most recent pair of eyeglasses was lost or destroyed for reasons beyond the control of the recipient. Necessary Contact 2 units (1 unit per eye) every year ages 20 and under in lieu of frame and lenses if the following criteria is met: Lenses A diagnosis of aphakia A diagnosis of monocular aphakia Necessary Contact Lens Replacement Non-Covered Services Surgical eye care. 2 units (1 unit per eye) every year ages 20 and under if the following criterion is met: The most recent pair of contact lenses was lost or destroyed for reasons beyond the control of the recipient, AND The member has one of the following diagnoses: Aphakia Monocular aphakia Revised June 24, 2015 Page 4 of 5

5 South Carolina Information 1.4 Molina Healthcare of South Carolina MMP Reimbursement Procedures The MMP benefit includes a $150 retail allowance toward the cost of frame and lenses including lens extras. Providers should bill the current and appropriate HCPCS codes for frames and lenses along with the usual and customary charges for those codes. Reimbursement will be the lesser of billed charges or the contracted rate of $115. The allowance does not apply to routine eye exams. Routine eye exams are paid separately. Frames and Lenses The allowance for frames and lenses will be applied in the following order: 1. Basic lens codes (V2100-V2399) 2. Frame codes (V2020, V2025) 3. Any remaining allowance will be applied to lens upgrades such as tinting, scratch coating, polycarbonate lenses, etc. The following example assumes a $150 allowance, a contracted rate of $115 and a billed amount more than the allowance. Service Code Description Billed Charges Paid Amount V2020 Frame $ $ V2100 Lens $ $ V2745 Tint $ $ Fitting $ $ 0.00 Total $ * $ *Member is responsible for charges exceeding their $150 benefit allowance. In this example, the member is responsible for $10. The following example assumes a $150 allowance, a contracted rate of $115 and a billed amount less than the allowance. Service Code Description Billed Charges Paid Amount V2020 Frame $ $ V2100 Lens $ $ Total $ $ Revised June 24, 2015 Page 5 of 5