DO NOT PUBLISH

Title of Rule:Revision to the Medical Assistance Rule Concerning Vision Services, Section 8.203

Rule Number:MSB 17-01-30-A

Division / Contact / Phone:Health Benefits and Operations Division / Amanda Forsythe / x6459

RULES ACTION SUMMARY AND FILING INSTRUCTIONS

SUMMARY OF ACTION ON RULE(S)

1.Department / Agency Name: / Health Care Policy and Financing / Medical Services Board
2.Title of Rule: / MSB 17-01-30-A, Revision to the Medical Assistance Rule Concerning Vision Services, Section 8.203
3.This action is an adoption of: / new rules
4.Rule sections affected in this action (if existing rule, also give Code of Regulations number and page numbers affected):
Sections(s) 8.203, Colorado Department of Health Care Policy and Financing, Staff Manual Volume 8, Medical Assistance (10 CCR 2505-10).
5.Does this action involve any temporary or emergency rule(s)? / No
If yes, state effective date:
Is rule to be made permanent? (If yes, please attach notice of hearing). / <Select One>

PUBLICATION INSTRUCTIONS*

Insert the new text beginning at 8.203 through the end of 8.203. This rule is effective September 30, 2017.

*to be completed by MSB Board Coordinator

DO NOT PUBLISH

Title of Rule:Revision to the Medical Assistance Rule Concerning Vision Services, Section 8.203

Rule Number:MSB 17-01-30-A

Division / Contact / Phone:Health Benefits and Operations Division / Amanda Forsythe / x6459

STATEMENT OF BASIS AND PURPOSE

  1. Summary of the basis and purpose for the rule or rule change. (State what the rule says or does and explain why the rule or rule change is necessary).

This rule codifies Colorado Medicaid vision services benefit coverage policy into administrative rule at Section 8.203. Currently, the Department's vision services policy is outlined in the provider billing manual. The adoption of this rule would clarify the amount, duration, and scope of covered vision services, as well as improve the ability of the Department to enforce the vision services benefit coverage policy.

Additionally, this rule clarifies the coverage policy for preventive eye examinations by explicitly stating that, in addition to covering such examinations for clients 20 years of age and younger, Colorado Medicaid covers annual preventive eye examinations for Colorado Medicaid clients 21 years of age and older.

  1. An emergency rule-making is imperatively necessary

to comply with state or federal law or federal regulation and/or

for the preservation of public health, safety and welfare.

Explain:

  1. Federal authority for the Rule, if any:
  1. State Authority for the Rule:

25.5-1-301 through 25.5-1-303, C.R.S. (2015);

25.5-5-202(1)(d) - (e), C.R.S. (2016)

Initial Review04/14/17Final Adoption08/11/17

Proposed Effective Date09/30/17Emergency Adoption

DOCUMENT #06

DO NOT PUBLISH

Title of Rule:Revision to the Medical Assistance Rule Concerning Vision Services, Section 8.203

Rule Number:MSB 17-01-30-A

Division / Contact / Phone:Health Benefits and Operations Division / Amanda Forsythe / x6459

REGULATORY ANALYSIS

  1. Describe the classes of persons who will be affected by the proposed rule, including classes that will bear the costs of the proposed rule and classes that will benefit from the proposed rule.

Currently, the vision services benefit coverage policy is available only in the provider billing manual. Adopting this rule will impact enrolled providers of vision services and Colorado Medicaid clients by increasing the transparency of and ease of access to the Department's coverage policy for this benefit. Specifically, by explicitly stating that Colorado Medicaid covers annual preventative eye examinations for adult clients, the Department predicts that more adult clients will take advantage of this benefit.

  1. To the extent practicable, describe the probable quantitative and qualitative impact of the proposed rule, economic or otherwise, upon affected classes of persons.

This rule will likely have a positive impact on Colorado Medicaid adult clients who were unaware that annual preventative eye examinations were a covered vision services benefit.

  1. Discuss the probable costs to the Department and to any other agency of the implementation and enforcement of the proposed rule and any anticipated effect on state revenues.

None.

  1. Compare the probable costs and benefits of the proposed rule to the probable costs and benefits of inaction.

There are no benefits to inaction; the cost is that Colorado Medicaid adult clients go without annual preventative eye examinations.

  1. Determine whether there are less costly methods or less intrusive methods for achieving the purpose of the proposed rule.

There are no less costly or less intrusive methods for achieving the purpose of the proposed rule.

  1. Describe any alternative methods for achieving the purpose for the proposed rule that were seriously considered by the Department and the reasons why they were rejected in favor of the proposed rule.

None.

8.202.5 ELIGIBLE CLIENTS

Dental services described in this Section 8.202 shall apply to Child Clients age 20 years and under.

8.203VISION SERVICES

8.203.1 Definitions

Adult Client means a Colorado Medicaid client 21 years of age or older.

Comprehensive Eye Exam means the examination, diagnosis, treatment, and management of diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identified related systemic conditions affecting the eye.

Low Vision Aid means one of a range of magnification devices that may be necessary to supplement eyeglasses for people with vision loss or low vision.

Refractive Error means a failure of the eye to focus images sharply on the retina, causing blurred vision.

8.203.2 Client Eligibility

8.203.2.A.All Colorado Medicaid clients are eligible for covered vision services, subject to the service-specific criteria and restrictions detailed in this section 8.203.

8.203.3 Provider Eligibility

8.203.3.A.Ordering, Prescribing, Referring (OPR) Providers

1.The following providers are eligible to order, prescribe, or refer vision services when enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business:

a.Optometrists

b.Ophthalmologists

c.Physicians

8.203.3.B. Rendering Providers

1.The following providers are eligible to render vision services when enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business:

a.Optometrists

b.Ophthalmologists

c.Opticians

8.203.4 Covered Services

8.203.4.A. Examinations and Eye Care Services

  1. Comprehensive Eye Exam (CEE)
  1. Limited to one (1) comprehensive eye exam per client, per calendar year.

2.Post-Comprehensive Eye Exam Follow-Up Visit

  1. Covered if medically necessary, as defined in section 8.076.1.8, to address a change in client’s condition.

3.Orthoptic and Pleoptic Vision Therapy

  1. Covered for a client 20 years of age or younger, when medically necessary, as defined in section 8.076.1.8.

8.203.4.B.Eyeglasses

  1. Frames and Lenses – Adult Clients
  1. Frames and lenses are covered for an Adult Client if:

i)Client has previously undergone eye surgery; and

ii)Medically necessary, as defined in section 8.076.1.8.

  1. Covered frames and lenses for an Adult Client are limited to:

i) One (1) eyeglasses frame; and

ii)Up to two (2) lenses that are:

1)Single or multi-focal;

2)Clear glass or plastic; and

3)Without filters or coatings.

  1. Limited to one (1) pair of eyeglasses per Adult Client, per 24-month period.
  1. Frames and Lenses – Clients 20 Years of Age or Younger
  1. Frames and lenses are covered for a client 20 years of age or younger if:

i) Medically necessary, as defined in section 8.076.1.8;

ii) Prescribed by a provider who meets the criteria at 8.203.3.A.; and

iii) Purchased through a provider who meets the criteria at 8.203.3.B.

  1. Per prescription, covered frames and lenses for a client 20 years of age or younger are limited to:

i) One (1) eyeglasses frame; and

ii) Up to two (2) lenses that are:

1) Single or multi-focal; and

2) Clear glass, plastic, or polycarbonate.

8.203.4.C.Contact Lenses

  1. Contact lenses are covered for an Adult Client if:
  1. Client meets the criteria for eyeglasses frames and lenses in section 8.203.4.B.1.a.; and
  2. Eyeglasses are not sufficient to treat the client’s refractive error.

2.Contact lenses are covered for a client 20 years of age or younger if:

  1. Client meets criteria for eyeglasses frames and lenses in section 8.203.4.B.2.a.; and
  2. Eyeglasses are not sufficient to treat the client’s refractive error.

8.203.4.D.Ocular Prosthetics

Ocular prosthetics are covered for all clients when medically necessary, as defined in section 8.076.1.8.

8.203.4.E.Low Vision Aids

Low Vision Aids are covered for a client 20 years of age or younger when medically necessary, as defined at section 8.076.1.8.

8.203.4.F.Eyewear Replacement

  1. Eyewear replacement is covered for a client 20 years of age or younger in the event of:
  1. Loss;
  1. A change in prescription; or
  2. Damage, if the cost to repair exceeds the cost of replacement.

2.Eyewear replacement for a client 20 years of age or younger is limited to the following types of eyewear:

  1. Eyeglasses frames and lenses;
  1. Contact lenses;
  2. Ocular prosthetics; and
  3. Low vision aids.

3.Eyewear replacement is not covered for Adult Clients.

8.203.5 Prior Authorization

8.203.5.A.Prior authorization is not required for vision services described in section 8.203.4.

8.203.6 Limitations, Exceptions, Non-Covered Services

8.203.6.A.Non-Covered Services

1.LASIK surgery and other eye surgeries which are not medically necessary.

8.205MEDICAID MANAGED CARE PROGRAM