OAR 410-140-0140: Vision Coverage

(1) The Division covers: (a) Ocular prosthesis (e.g., artificial eye) and related services (OAR 410-122-0640). (b) Reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the Prioritized list. When a diagnosis is established for a service, treatment, or item that falls below the funding line, the Division may not cover any other services related to the diagnosis unless the member meets the comorbidity rules (OAR 410-141-3820(10) & (11)). (c) Orthoptic and pleoptic training or “vision therapy” under EPSDT (refer to Division 410, Chapter 151) as followed: (A) When therapy treatment pairs with a covered diagnosis on the Prioritized List; and (B) Limited to six (6) sessions per calendar year (no PA required): (i) The initial evaluation is included in the six (6) therapy sessions; (ii) Additional therapy sessions require PA (OAR 410-140-0420); (iii) Providers shall develop a therapy treatment plan and regimen that shall be taught to the member, family, foster parents, and caregiver during the therapy treatments. No extra treatments shall be authorized for teaching; (iv) Therapy that can be provided by the member, family, foster parents, and caregiver is not a reimbursable service; and (v) All vision therapy services including the initial evaluation shall be billed to the Division with the Current Procedural Terminology (CPT) code for orthoptic and pleoptic training. (2) Division members are enrolled for covered health services to be delivered through one of the following means: (a) Managed Care Entity (MCE) as defined in OAR 410-120-0000. Payment for all vision services provided to MCE members by ophthalmologists, optometrists, and opticians is a matter between the provider and the MCE; (b) Fee-for-service (FFS): (A) FFS members are not enrolled in an MCE and may receive vision services from any Division-enrolled provider that accepts FFS members subject to limitations and restrictions in the visual services program rules; and (B) All claims must be billed directly to the Division. (3) When a member has both Medicare and coverage through the Division, optometrists and ophthalmologists shall bill Medicare first for Medicare covered services. (4) When a member has third party liability (TPL) and coverage through the Division, optometrists and ophthalmologists shall bill TPL first for TPL covered services. (5) When an OHP member receives services on a FFS basis under the Division’s rules and has Medicare or TPL coverage: (a) A provider may order visual materials from any visual materials supplier; and (b) The Division does not require PA for Medicare or TPL covered services. (6) Coverage for eligible adults (age 21 and older): (a) One complete examination and determination of refractive state is limited to once every 24 months for non-pregnant members; (b) One complete examination and determination of refractive state is limited to once (1) every 24 months for pregnant members and during the protected post-partum 12-month period (OAR 410-200-0135). (c) Diagnostic evaluations and medical examinations are not limited if documentation in the physician's or optometrist's clinical record justifies the medical need for diagnosis; (d) Ophthalmological intermediate and comprehensive exam services are not limited for allowable medical diagnosis; (e) Visual services for the purpose of prescribing glasses or contact lenses and fitting fees are as follows: (A) When determined necessary during a limited complete examination and determination of refractive state for pregnant members and during the protected post-partum 12-month period (OAR 410-200-0135). (B) Non-pregnant adults are not covered, except when the member: (i) Has a medical diagnosis of aphakia, pseudophakia, congenital aphakia, keratoconus; or (ii) Lacks the natural lenses of the eye due to surgical removal (e.g., cataract extraction) or congenital absence; or (iii) Has had a keratoplasty surgical procedure (e.g., corneal transplant) with limitations described in OAR 410-140-0160 (Contact Lens Services and Supplies). (7) OHP Plus Children (birth through age 20): (a) All ophthalmological examinations and vision services, including routine vision exams, fittings, repairs, and materials are covered when documentation in the clinical record justifies the medical need; (b) The standard of care and expectation is that all comprehensive eye exams for children be dilated. (c) With the diagnosis of Amblyopia, band-aid patches treatment shall be covered with a prescription. Quantity limit is sixty (60) per thirty (30) days. (8) Refraction determination is not limited following a diagnosed medical condition (e.g., multiple sclerosis). (9) The Division reimburses all covered surgical procedures as global packages, except when the surgeon codes the surgical procedure with a modifier indicating surgical procedure only, excluding post-operative care. (10) The Division OHP vision benefit packages: (a) For non-pregnant adults (age 21 and older), visual services and materials to diagnose and correct disorders of refraction and accommodation are covered only when the member: (A) Has a covered medical diagnosis, following cataract surgery or a corneal lens transplant as described in OAR 410-140-0140; or (B) Is in their protected post-partum 12-month period (see OAR 410-200-0135); (b) For pregnant adult people (age 21 and older) other visual services are covered with limitations as described in these rules; (c) For children (birth through age 20): Visual services are covered as described in this rule and without limitation when documentation in the clinical record justifies the medical need. (11) Post-operative care includes all related follow-up visits and examinations provided within: (a) Ninety (90) days following the date of major surgery; or (b) Ten (10) days following the date of minor surgery; and (c) Claims for evaluation and management services and ophthalmological examinations billed within the follow-up period shall be denied. (12) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.