Section 16.03.09.782 - VISION SERVICES: COVERAGE AND LIMITATIONSThe Department will pay for vision services and supplies in accordance with the guidelines and limitations listed below.
01.Eye Examinations. a. The Department will pay participating physicians and optometrists for one (1) eye examination during any twelve (12) month period to determine the need for glasses to correct a refractive error.b. The Department will pay for eyeglasses within Department guidelines following a diagnosis of visual defects and a recommendation that eyeglasses are needed for correction of a refractive error.02.Lenses. Lenses, single vision or bifocal, will be purchased by the Department not more often than once every four (4) years except when there is documentation of a major visual change as defined by the Department. a. Scratch resistant coating is required for all plastic and polycarbonate lensesb. Payment for tinted lenses will only be made when there is a diagnosis of albinism or in the case of other extreme medical conditions as defined by the Department as defined in the Provider Handbook. Documentation must be kept on file by both the examining and supplying providers.c. All contact lenses require prior authorization by the Department. Contact lenses will be covered for participants only with documentation of: i. A need for correction equal to or greater than plus or minus ten (±10) diopters; orii. An extreme medical condition that does not allow correction through the use of conventional lenses, such as cataract surgery, keratoconus, anisometropia, or other extreme conditions as defined by the Department.03.Replacement Lenses. Replacement lenses will be purchased for participants under the age of twenty-one (21) prior to the four (4) year limitation only with documentation of a major visual change as defined by the Department in the Idaho Medicaid Provider Handbook. Replacement lenses for participants age twenty-one (21) and older will be purchased when necessary to prevent permanent damage to the eye.04.Frames. Frames will be purchased according to the following guidelines: a. One (1) set of frames will be purchased by the Department for eligible participants not more often than once every four (4) years;b. When it is documented by the vision provider that there has been a major change in visual acuity that cannot be accommodated in lenses that will fit in the existing frames, new frames also may be authorized.05.Fitting Fees. Fitting fees for either contact lenses or conventional frames and lenses are covered only when the participant is eligible under the Medicaid program guidelines to receive the supplies associated with the fitting fee.06.Non-Covered Items. A Medicaid Provider may receive payment from a Medicaid participant for vision services that are either not covered by the State Plan, or include special features or characteristics that are desired by the participant but are not medically necessary.a. Non-covered items include Trifocal lenses, Progressive lenses, photo gray, and tint.b. Replacement of broken, lost, or missing glasses is the responsibility of the participant.Idaho Admin. Code r. 16.03.09.782