Chapter 182-544 WAC
Last Update: 6/29/17VISION CARE
WAC Sections
VISION CARE—CLIENTS TWENTY YEARS OF AGE AND YOUNGER | ||
| HTMLPDF | 182-544-0010 | Vision care—General. |
| HTMLPDF | 182-544-0050 | Vision care—Definitions. |
| HTMLPDF | 182-544-0100 | Vision care—Eligible persons—Twenty years of age and younger. |
| HTMLPDF | 182-544-0150 | Vision care—Provider requirements. |
| HTMLPDF | 182-544-0250 | Vision care—Covered eye services (examinations, refractions, visual field testing, and vision therapy). |
| HTMLPDF | 182-544-0300 | Vision care—Covered eyeglasses (frames and lenses)—Clients age twenty and younger. |
| HTMLPDF | 182-544-0325 | Vision care—Covered eyeglass frames and repairs—Clients age twenty and younger. |
| HTMLPDF | 182-544-0350 | Vision care—Covered eyeglass lenses—Clients age twenty and younger. |
| HTMLPDF | 182-544-0400 | Vision care—Covered contact lenses—Clients age twenty and younger. |
| HTMLPDF | 182-544-0500 | Vision care—Covered ocular prosthetics. |
| HTMLPDF | 182-544-0550 | Vision care—Covered eye surgery. |
| HTMLPDF | 182-544-0560 | Vision care—Authorization. |
| HTMLPDF | 182-544-0575 | Vision care—Noncovered eyeglasses and contact lenses. |
| HTMLPDF | 182-544-0600 | Vision care—Payment methodology. |
PDF182-544-0010
Vision care—General.
(1) The medicaid agency covers the vision care services listed in this chapter for clients age twenty and younger, according to agency rules and subject to the limitations and requirements in this chapter. The agency pays for vision care when it is:
(a) Covered;
(b) Within the scope of the client's benefit package;
(c) Medically necessary as defined in WAC 182-500-0070;
(d) Authorized, as required within this chapter, chapter 182-501 WAC, and the agency's published billing instructions; and
(e) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions.
(2) The agency does not require prior authorization for covered vision care services that meet the clinical criteria set forth in this chapter.
(3) The agency requires prior authorization for covered vision care services when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.
(4) The agency evaluates requests for covered services that do not meet clinical criteria based on the definition of medical necessity in WAC 182-500-0070 and the process in WAC 182-501-0165.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0010, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0010, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-544-0010, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0010, filed 6/6/05, effective 7/7/05.]
PDF182-544-0050
Vision care—Definitions.
The following definitions and those found in chapter 182-500 WAC apply to this chapter. Unless otherwise defined in this chapter, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington.
"Blindness" - A diagnosis of visual acuity for distance vision of twenty/two hundred or worse in the better eye with best correction or a limitation of the client's visual field (widest diameter) subtending an angle of less than twenty degrees from central.
"Conventional soft contact lenses" or "rigid gas permeable contact lenses" - FDA-approved contact lenses that do not have a scheduled replacement (discard and replace with new contacts) plan. The soft lenses usually last one year, and the rigid gas permeable lenses usually last two years. Although some of these lenses are designed for extended wear, the medicaid agency generally approves only those lenses that are designed to be worn as daily wear (remove at night).
"Disposable contact lenses" - FDA-approved contact lenses that have a planned replacement schedule (e.g., daily, every two weeks, monthly, quarterly). The contacts are then discarded and replaced with new ones as scheduled. Although many of these lenses are designed for extended wear, the agency generally approves only those lenses that are designed to be worn as daily wear (remove at night).
"Expedited prior authorization" - A form of authorization used by the provider to certify that the agency-published clinical criteria for a specific vision care service(s) have been met.
"Extended wear soft contacts" - Contact lenses that are designed to be worn for longer periods than daily wear (remove at night) lenses. These can be conventional soft contact lenses or disposable contact lenses designed to be worn for several days and nights before removal.
"Hardware" - Eyeglass frames and lenses and contact lenses.
"Prior authorization" - A form of authorization used by the provider to obtain the agency's written approval for a specific vision care service(s). The agency's approval is based on medical necessity and must be received before the service(s) are provided to clients as a precondition for payment.
"Specialty contact lens design" - Custom contact lenses that have a more complex design than a standard spherical lens. These specialty contact lenses (e.g., lenticular, aspheric, or myodisc) are designed for the treatment of specific disease processes, such as keratoconus, or are required due to high refractive errors. This definition of specialty contact lens does not include lenses used for surgical implantation.
"Stable visual condition" - A client's eye condition has no acute disease or injury; or the client has reached a point after any acute disease or injury where the variation in need for refractive correction has diminished or steadied. The client's vision condition has stabilized to the extent that eyeglasses or contact lenses are appropriate and that any prescription for refractive correction is likely to be sufficient for one year or more.
"Visual field exams or testing" - A process to determine defects in the field of vision and test the function of the retina, optic nerve and optic pathways. The process may include simple confrontation to increasingly complex studies with sophisticated equipment.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0050, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0050, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0050, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0050, filed 12/6/00, effective 1/6/01.]
PDF182-544-0100
Vision care—Eligible persons—Twenty years of age and younger.
This section applies to eligible persons who are twenty years of age and younger.
(1) Vision care is available to persons who are eligible for services under one of the Washington apple health programs listed in the table in WAC 182-501-0060 or are eligible for the alien emergency medical (AEM) program as described in WAC 182-507-0110.
(2) Eligible persons who are enrolled in an agency-contracted managed care organization (MCO) are eligible under fee-for-service for covered vision care that is not covered by their plan, subject to the provisions of this chapter and other applicable WAC.
[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-544-0100, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-544-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0100, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0100, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0100, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0100, filed 12/6/00, effective 1/6/01.]
PDF182-544-0150
Vision care—Provider requirements.
(1) Enrolled/contracted eye care providers must:
(a) Meet the requirements in chapter 182-502 WAC;
(b) Provide only those services that are within the scope of the provider's license;
(c) Obtain all hardware (including the tinting of eyeglass lenses) and contact lenses for clients from the medicaid agency's designated supplier as published in the agency's current vision care billing instructions; and
(d) Return all unclaimed hardware and contact lenses to the agency's designated supplier using a postage-paid envelope furnished by the supplier.
(2) The following providers are to enroll/contract with the agency to provide and bill for vision care services furnished to clients:
(a) Ophthalmologists;
(b) Optometrists;
(c) Opticians; and
(d) Ocularists.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0150, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0150, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0150, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0150, filed 12/6/00, effective 1/6/01.]
PDF182-544-0250
Vision care—Covered eye services (examinations, refractions, visual field testing, and vision therapy).
See WAC 182-531-1000 Ophthalmic services.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0250, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0250, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0250, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0250, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0250, filed 12/6/00, effective 1/6/01.]
PDF182-544-0300
Vision care—Covered eyeglasses (frames and lenses)—Clients age twenty and younger.
(1) The medicaid agency covers eyeglasses once every twelve months for clients when the following clinical criteria are met:
(a) The client has a stable visual condition;
(b) The client's treatment is stabilized;
(c) The prescription is less than eighteen months old; and
(d) One of the following minimum correction needs in at least one eye is documented in the client's file:
(i) Sphere power equal to, or greater than, plus or minus 0.50 diopter;
(ii) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or
(iii) Add power equal to, or greater than, 1.0 diopter for bifocals and trifocals.
(2) If the client has a diagnosis of accommodative esotropia or any strabismus correction, the limitations of subsection (1) of this section do not apply.
(3) The agency covers one pair of back-up eyeglasses for clients who wear contact lenses as their primary visual correction aid (see WAC 182-544-0400(1)) limited to once every two years.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0300, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0300, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0300, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0300, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0300, filed 12/6/00, effective 1/6/01.]
PDF182-544-0325
Vision care—Covered eyeglass frames and repairs—Clients age twenty and younger.
(1) The medicaid agency covers durable or flexible frames when the client has a diagnosed medical condition that contributes to broken eyeglass frames. To receive payment, the provider must order the "durable" or "flexible" frames through the agency's designated supplier.
(2) The agency covers all of the following for clients:
(a) Coating contract eyeglass frames to make the frames nonallergenic. Clients must have a medically diagnosed and documented allergy to the materials in the available eyeglass frames.
(b) Four incidental repairs to a client's eyeglass frames in a calendar year. To receive payment, all of the following must be met:
(i) The provider typically charges the general public for the repair or adjustment;
(ii) The contractor's one year warranty period has expired; and
(iii) The cost of the repair does not exceed the agency's cost for replacement frames and a fitting fee.
(c) Up to two replacement eyeglass frames in a calendar year when the eyeglass frames have been lost or broken. Lost or broken eyeglass frames must be documented in the client's medical record.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0325, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0325, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0325, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0325, filed 6/24/08, effective 7/25/08.]
PDF182-544-0350
Vision care—Covered eyeglass lenses—Clients age twenty and younger.
(1) The medicaid agency covers the following plastic scratch-resistant eyeglass lenses:
(a) Single vision lenses;
(b) Round or flat top D-style bifocals;
(c) Flat top trifocals;
(d) Slab-off and prism lenses (including Fresnel lenses);
(e) Plastic photochromatic lenses when the client's medical need is diagnosed and documented as ocular albinism or retinitis pigmentosa;
(f) Polycarbonate lenses when the client's medical need is diagnosed and documented as one of the following:
(i) Blind in one eye and needs protection for the other eye, regardless of whether a vision correction is required;
(ii) Infants and toddlers with motor ataxia;
(iii) Strabismus or amblyopia;
(iv) Seizure disorder, cerebral palsy, autism, attention deficit hyperactivity disorder (ADHD), developmental delay, Down syndrome, bipolar, schizophrenia, or multiple sclerosis.
(g) Bifocal lenses to be replaced with single vision or trifocal lenses, or trifocal lenses to be replaced with bifocal or single vision lenses when:
(i) The client has attempted to adjust to the bifocals or trifocals for at least sixty days;
(ii) The client is unable to make the adjustment; and
(iii) The trifocal lenses being replaced are returned to the provider.
(2) Eyeglass lenses covered under subsection (1) of this section must be placed into a frame that is, or was, purchased by the agency.
(3) The agency covers the following high index lenses for clients when clinical criteria are met. The client's medical need in at least one eye must be diagnosed and documented as:
(a) A spherical refractive correction of plus or minus six diopters or greater; or
(b) A cylinder correction of plus or minus three diopters or greater.
(4) The agency covers the tinting of plastic lenses when the client's medical need is diagnosed and documented as one or more of the following chronic (expected to last longer than three months) eye conditions causing photophobia:
(a) Blindness;
(b) Chronic corneal keratitis;
(c) Chronic iritis, iridocyclitis;
(d) Diabetic retinopathy;
(e) Fixed pupil;
(f) Glare from cataracts;
(g) Macular degeneration;
(h) Migraine disorder;
(i) Ocular albinism;
(j) Optic atrophy or optic neuritis;
(k) Rare photo-induced epilepsy conditions; or
(l) Retinitis pigmentosa.
(5) The agency covers up to four replacement lenses in a calendar year when the lenses are lost or broken. Lost or broken lenses must be documented in the client's medical record.
(6) The agency covers replacement lenses when the client meets one of the following clinical criteria:
(a) Eye surgery or the effects of prescribed medication or one or more diseases affecting vision:
(i) The client has a stable visual condition;
(ii) The client's treatment is stabilized;
(iii) The lens correction must have a 1.0 or greater diopter change between the sphere or cylinder correction in at least one eye; and
(iv) The previous and new refraction are documented in the client's medical record.
(b) Headaches, blurred vision, or visual difficulty in school or at work. In this case, all of the following must be documented in the client's medical record:
(i) Copy of current prescription (less than eighteen months old);
(ii) Date of last dispensing, if known;
(iii) Absence of a medical condition that is known to cause temporary visual acuity changes (e.g., diabetes, pregnancy, etc.); and
(iv) A refractive change of at least .75 diopter or greater between the sphere or cylinder correction in at least one eye.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0350, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0350, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0350, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, and 42 C.F.R. 440.120 and 440.225. WSR 05-17-153, § 388-544-0350, filed 8/22/05, effective 9/22/05; WSR 05-13-038, § 388-544-0350, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0350, filed 12/6/00, effective 1/6/01.]
PDF182-544-0400
Vision care—Covered contact lenses—Clients age twenty and younger.
(1) The medicaid agency covers contact lenses as the client's primary refractive correction method when the client has a spherical correction of plus or minus 6.0 diopters or greater in at least one eye. See subsection (4) of this section for exceptions to the plus or minus 6.0 diopter criteria. The spherical correction may be from the prescription for the glasses or the contact lenses and may be written in either "minus cyl" or "plus cyl" form.
(2) The agency covers the following contact lenses:
(a) Conventional soft contact lenses or rigid gas permeable contact lenses that are prescribed for daily wear; or
(b) Disposable contact lenses that are prescribed for daily wear and have a monthly or quarterly planned replacement schedule, as follows:
(i) Twelve pairs of monthly replacement contact lenses; or
(ii) Four pairs of three-month replacement contact lenses.
(3) The agency covers soft toric contact lenses for clients with astigmatism when the following clinical criteria are met:
(a) The client's cylinder correction is plus or minus 1.0 diopter in at least one eye; and
(b) The client meets the spherical correction listed in subsection (1) of this section.
(4) The agency covers contact lenses when the following clinical criteria are met. In these cases, the limitations in subsection (1) of this section do not apply.
(a) For clients diagnosed with high anisometropia.
(i) The client's refractive error difference between the two eyes is at least plus or minus 3.0 diopters between the sphere or cylinder correction; and
(ii) Eyeglasses cannot reasonably correct the refractive errors.
(b) Specialty contact lens designs for clients who are diagnosed with one or more of the following:
(i) Aphakia;
(ii) Keratoconus; or
(iii) Corneal softening.
(c) Therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery.
(5) The agency covers replacement contact lenses for clients when lost or damaged.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0400, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0400, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0400, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0400, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0400, filed 12/6/00, effective 1/6/01.]
PDF182-544-0500
Vision care—Covered ocular prosthetics.
See WAC 182-531-1000 Opthalmic services.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0500, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0500, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0500, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0500, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0500, filed 12/6/00, effective 1/6/01.]
PDF182-544-0550
Vision care—Covered eye surgery.
See WAC 182-531-1000 Ophthalmic services.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0550, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0550, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0550, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0550, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0550, filed 12/6/00, effective 1/6/01.]
PDF182-544-0560
Vision care—Authorization.
(1) The medicaid agency requires providers to obtain authorization for covered vision care services as required in this chapter.
(a) For prior authorization (PA), a provider must submit a written request to the agency as specified in the agency's published vision care billing instructions.
(b) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the agency's published vision care billing instructions. The appropriate EPA number must be used when the provider bills the agency.
(c) Upon request, a provider must provide documentation to the agency showing how the client's condition met the criteria for PA or EPA.
(2) Authorization requirements in this chapter are not a denial of service.
(3) When a service requires authorization, the provider must properly request authorization in accordance with the agency's rules and billing instructions.
(4) When authorization is not properly requested, the agency rejects and returns the request to the provider for further action. The agency does not consider the rejection of the request to be a denial of service.
(5) The agency's authorization of service(s) does not necessarily guarantee payment.
(6) The agency evaluates requests for authorization of covered vision care services that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 182-501-0169.
(7) The agency may recoup any payment made to a provider if the agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 182-502-0100.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0560, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0560, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0560, filed 6/24/08, effective 7/25/08.]
PDF182-544-0575
Vision care—Noncovered eyeglasses and contact lenses.
(1) The agency does not cover the following:
(a) Executive style eyeglass lenses;
(b) Bifocal contact lenses;
(c) Daily and two week disposable contact lenses;
(d) Extended wear soft contact lenses, except when used as therapeutic contact bandage lenses or for aphakic clients;
(e) Custom colored contact lenses;
(f) Glass lenses;
(g) Nonglare or anti-reflective lenses;
(h) Progressive lenses;
(i) Sunglasses and accessories that function as sunglasses (e.g., "clip-ons");
(j) Upgrades at private expense to avoid the medicaid agency's contract limitations (e.g., frames that are not available through the agency's contract or noncontract frames or lenses for which the client or other person pays the difference between the agency's payment and the total cost).
(2) A noncovered service may be requested as an exception to rule (ETR) as described in WAC 182-501-0160.
(3) When a noncovered service is recommended based on the early and periodic screening, diagnosis, and treatment (EPSDT) program, the agency evaluates the request for medical necessity based on the definition in WAC 182-500-0070 and the process in WAC 182-501-0165.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0575, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0575, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0575, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0575, filed 6/24/08, effective 7/25/08.]
PDF182-544-0600
Vision care—Payment methodology.
(1) To receive payment, vision care providers must bill the agency according to this chapter, chapters 182-501 and 182-502 WAC, and the medicaid agency's published billing instructions and numbered memoranda.
(2) The agency pays one hundred percent of the agency contract price for covered eyeglass frames, lenses, and contact lenses when these items are obtained through the agency's approved contractor.
(3) See WAC 182-531-1850 for professional fee payment methodology.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0600, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-544-0600, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0600, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0600, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0600, filed 12/6/00, effective 1/6/01.]