907 KAR 1:631. Reimbursement of Vision Program services.

 

      RELATES TO: KRS 205.520, 42 C.F.R. 440.40, 440.60, 447 Subpart B, 42 U.S.C. 1396a-d

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)

      NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes reimbursement provisions for vision services.

 

      Section 1. Definitions. (1) "Department" means the Department for Medicaid Services or its designated agent.

      (2) "Global Insight Index" means an indication of changes in health care costs from year to year developed by Global Insight.

      (3) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

      (4) "Ophthalmic dispenser" means a physician, optician, or optometrist, who is licensed to prepare and dispense lenses and eyeglasses in accordance with an original, written prescription.

      (5) "Resource-based relative value scale unit" or "RBRVS unit" means a value based on the service which takes into consideration the practitioners' work, practice expenses, liability insurance, and a geographic factor based on the prices of staffing and other resources required to provide the service in an area relative to national average price.

 

      Section 2. Reimbursement for Covered Procedures and Materials for Optometrists. (1) With the exception of materials or a laboratory service, reimbursement for a covered service, within the optometrist's scope of licensure, shall be based on the optometrist's usual and customary actual billed charges up to the fixed upper limit per procedure established by the department using the Kentucky Medicaid fee schedule, specified in 907 KAR 3:010, Section 3, developed from a resource-based relative value scale (RBRVS) on parity with physicians.

      (2) If an RBRVS based fee has not been established, the department shall set a reasonable fixed upper limit for the procedure. The upper limit shall be determined following a review of rates paid for the service by three (3) other sources. The average of these rates shall be compared with similar procedures paid by the department to set the upper limit for the procedure.

      (3) With the exception of the following dispensing services, the department shall use the Kentucky conversion factor for "all nonanesthesia related services" as established in 907 KAR 3:010, Section 3(2)(b):

      (a) Fitting of spectacles;

      (b) Special spectacles fitting; and

      (c) Repair and adjustment of spectacles.

      (4) Reimbursement for a dispensing service fee or a repair service fee shall be as follows:

 

Procedure

Upper Limit

92340 (Fitting of spectacles)

$33

92341 (Fitting of spectacles)

$38

92352 (Special spectacles fitting)

$33

92353 (Special spectacles fitting)

$39

92370 (Repair & adjust spectacles)

$29

 

      (5) The department shall:

      (a) Reimburse for:

      1. A single vision lens at twenty-eight (28) dollars per lens;

      2. A bifocal lens at forty-three (43) dollars per lens; and

      3. A multi-focal lens at fifty-six (56) dollars per lens; and

      (b) Annually adjust the rates established in paragraph (a) of this subsection by the Global Insight Index.

      (6)(a) The department shall reimburse for frames or a part of frames (not lenses) at the optical laboratory cost of the materials not to exceed the upper limit for materials as established by the department.

      (b) The upper payment limit for frames shall be fifty (50) dollars.

      (c) An optical laboratory invoice, or proof of actual acquisition cost of materials, shall be maintained in the recipient's medical records for postpayment review.

      (7)(a) Reimbursement for a covered clinical laboratory service shall be based on the Medicare allowable payment rates.

      (b) For a laboratory service with no established allowable payment rate, the payment shall be sixty-five (65) percent of the usual and customary actual billed charges.

 

      Section 3. Maximum Reimbursement for Covered Procedures and Materials for Ophthalmic Dispensers. Reimbursement for a covered service within the ophthalmic dispenser's scope of licensure shall be in accordance with Section 2 of this administrative regulation.

 

      Section 4. Reimbursement Limitations. (1) A telephone consultation shall be excluded from payment.

      (2) Contact lenses shall be excluded from payment.

      (3) Safety glasses shall be covered if proof of medical necessity is documented.

      (4) A prism, if medically necessary, shall be added within the cost of the lenses.

      (5) A press-on prism shall be excluded from payment.

 

      Section 5. Third Party Liability. Nonduplication of payments and third-party liability shall be in accordance with 907 KAR 1:005.

 

      Section 6. Appeal Rights. (1) An appeal of a negative action taken by the department regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

      (3) An appeal of a negative action taken by the department regarding a Medicaid provider shall be in accordance with 907 KAR 1:671. (21 Ky.R. 218; eff. 9-21-94; 23 Ky.R. 4015; 24 Ky.R. 120; eff. 6-18-97; 27 Ky.R. 1105; eff. 12-21-2000; 34 Ky.R. 1847; 2121; eff. 4-4-08.)