Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER VIS-35 June 2006 TO: Vision Care Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Vision Care Manual (Coverage of Vision Care Services for Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover the following vision care services when provided to eligible MassHealth members of all ages: ophthalmic materials, including but not limited to, complete eyeglasses or eyeglass parts, the dispensing of ophthalmic materials, certain contact lenses, and other visual aids. These services and materials will no longer be restricted to eligible MassHealth members under age 21. In addition, visual magnifying aids for eligible MassHealth members aged 21 years or older will no longer be restricted to those members who are both diabetic and legally blind. Also effective July 1, 2006, providers may use Service Code T2002 for an optometrist or optician nursing facility visit for the pickup of a new prescription and fitting of eyeglasses, the delivery and adjustment of new eyeglasses, the pickup of broken eyeglasses, or the delivery of repaired eyeglasses. MassHealth will pay only for the first member seen at the nursing facility during a single visit for the services described and billed using Service Code T2002. MassHealth will not pay for additional members seen during that same visit. This letter transmits revisions to the vision care regulations and to Subchapter 6 of the Vision Care Manual, that reflect these changes. All other conditions of 130 CMR 402.000 and 450.000 continue to apply. The regulations were filed as emergency regulations, effective July 1, 2006. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Vision Care Manual Pages iv, vii, 4-1 through 4-4, 6-5, and 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Vision Care Manual Page iv — transmitted by Transmittal Letter VIS-29 Page vii — transmitted by Transmittal Letter VIS-30 Pages 4-1 through 4-4 — transmitted by Transmittal Letter VIS-32 Pages 6-5 and 6-6 — transmitted by Transmittal Letter VIS-34 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 4. Program Regulations 402.401: Introduction 41 402.402: Definitions 41 402.403: Eligible Members 42 402.404: Provider Eligibility 42 402.405: Nonreimbursable Circumstances 43 432.406: Maximum Allowable Fees 43 402.407: Individual Consideration 43 402.408: Prior Authorization 44 402.409: Separate Procedure 44 (130 CMR 402.410 through 402.415 Reserved) 402.416: Prescription and Dispensing Requirements 45 402.417: Recordkeeping Requirements 46 402.418: Services Provided Outside the Office 47 (130 CMR 402.419 through 402.425 Reserved) 402.426: Service Limitations: Visual Analysis 48 402.427: Service Limitations: Time and Power Restrictions on Dispensing Eyeglasses 48 402.428: Service Limitations: Broken Eyeglasses 49 402.429: Service Limitations: Tinted Lenses 49 402.430: Service Limitations: Coated Lenses 410 402.431: Service Limitations: Two Pairs of Eyeglasses Instead of Bifocals 410 402.432: Service Limitations: Cataract Lenses 4-10 402.433: Service Limitations: Contact Lenses 410 402.434: Service Limitations: Extra or Spare Eyeglasses 411 402.435: Service Exclusions 411 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For vision care providers, those matters are covered in 130 CMR Chapter 402.000, reproduced as Subchapter 4 in the Vision Care Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("penandink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-1 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 402.401: Introduction (A) The regulations in 130 CMR 402.000 state the requirements and procedures for the purchase of vision care services under MassHealth. Vision care services are the professional care of the eyes for purposes of diagnosing and correcting refractive errors, analyzing muscular anomalies, and determining pathological conditions. They include eye examinations, vision training, and the prescription and dispensing of ophthalmic materials. Professional and technical services must be provided in accordance with the established standards of quality and health-care necessity recognized by the vision care industry and licensing agencies in Massachusetts. (B) All vision care providers participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 402.000 and 450.000. 402.402: Definitions The following terms used in 130 CMR 402.000 have the meanings given in 130 CMR 402.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 402.402 is not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 402.000 and in 130 CMR 450.000. Dispensing Practitioner – any optician, optometrist, ophthalmologist, or other participating provider authorized by the MassHealth agency to dispense eyeglass frames, lenses, and other vision care materials to members. Optical Supplier – the optical laboratory contracted by the MassHealth agency to supply the following ophthalmic materials and services: (1) eyeglass frames; (2) eyeglass lenses; (3) frame cases; (4) tints, coatings, groundon prisms, and prisms by decentration; and (5) repair parts. Order – the process by which a dispensing practitioner requests ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. Order Form – the form used by the dispensing practitioner to request ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. The required form is specified in the instructions in Subchapter 5 of the Vision Care Manual. Prescriber – any optometrist, ophthalmologist, or other practitioner licensed and authorized to write prescriptions for eyeglass frames, lenses, and other vision care services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-2 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 402.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for vision care services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. 402.404: Provider Eligibility Payment for services described in 130 CMR 402.000 will be made only to providers of vision care services who are participating in MassHealth on the date of service. The eligibility requirements for providers of vision care services are as follows. (A) In State. (1) Optometrists. A Massachusetts optometrist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration of Optometrists. (a) A Level I optometrist is one who is not qualified to apply topical agents. (b) A Level II optometrist is one who has completed the required course of study and passed the examination necessary to obtain certification to apply topical agents. (c) A Level III optometrist is one who is certified to prescribe, dispense, and administer therapeutic pharmaceutical agents (TPA) for abnormal ocular conditions and diseases. (2) Opticians. A Massachusetts optician is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration of Opticians. (3) Ophthalmologists. A Massachusetts ophthalmologist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration in Medicine. Ophthalmologists are governed by these regulations only with respect to the dispensing of ophthalmic materials. All other vision care services provided by ophthalmologists must be in compliance with the physician regulations of MassHealth. (4) Ocularists. A Massachusetts ocularist is eligible to participate in MassHealth only if certified by the National Examining Board of Ocularists. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-3 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 (B) Out of State. (1) Optometrists. An optometrist located outside of Massachusetts is eligible to receive payment for vision care services provided to Massachusetts members only if the optometrist is licensed to practice by the appropriate state's board of registration. (2) Opticians. An optician located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the optician is licensed to practice by the appropriate state's board of registration. (3) Ophthalmologists. An ophthalmologist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ophthalmologist is licensed to practice by the appropriate state's board of registration. Ophthalmologists are governed by 130 CMR 402.000 only with respect to the dispensing of ophthalmic materials. All other vision care services provided by ophthalmologists must be in compliance with the physician regulations of MassHealth at 130 CMR 433.000. (4) Ocularists. An ocularist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ocularist has been certified by the National Examining Board of Ocularists. 402.405: Nonreimbursable Circumstances Vision care services are not reimbursable to a vision care provider when the services were furnished in a state institution, in a hospital, or in a hospitalaffiliated teaching institution, and when the services are among those for which the provider is compensated by the state or institution. 402.406: Maximum Allowable Fees The Massachusetts Division of Health Care Finance and Policy (DHCFP) determines the maximum allowable fees for all vision care services and ophthalmic materials, except for those ophthalmic materials purchased through the optical supplier where the basis for the rates is set by the terms of the contract. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 402.000. The payment for a service will be the lower of the following: (A) the provider's usual and customary fee; or (B) the maximum allowable fee listed in the applicable DHCFP fee schedule. 402.407: Individual Consideration Some services listed in Subchapter 6 of the Vision Care Manual are designated "I.C.," an abbreviation for individual consideration. Individual consideration means that a fee could not be established. The payment for an individual-consideration service will be determined by the MassHealth agency’s professional advisors from the provider's descriptive report of the service furnished. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-4 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 402.408: Prior Authorization (A) For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the Vision Care Manual with the abbreviation "P.A." require prior authorization. These services include but are not limited to: (1) certain contact lenses; (2) low-vision aids; (3) fundus photographs; (4) unlisted services; (5) glass lenses; (6) special-needs glasses; (7) polycarbonate lenses for members aged 21 years or older, or for members of any age who are amblyopic or monocular; and (8) vision training. (B) All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Vision Care Manual. Prior authorization determines only the health-care necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. 402.409: Separate Procedure Some procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it is designated as a "separate procedure" or "S.P." in the service description. Thus, when a procedure is performed alone for a specific purpose, it must be considered a separate procedure. (130 CMR 402.410 through 402.415 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 603 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; and - straightforward medical decision making 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; and - medical decision making of low complexity 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; and - medical decision making of moderate complexity 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; and - medical decision making of high complexity 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; and - medical decision making of moderate to high complexity T2002 Nonemergency transportation, per diem (Use for home/nursing facility visit by an optometrist/ optician for the pickup of a new prescription and fitting of eyeglasses, the delivery and adjustment of new eyeglasses, the pickup of broken eyeglasses, or the delivery of repaired eyeglasses. Payable only for the first member seen during one such visit. Not payable for additional members seen during the same visit.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Vision Care Manual Transmittal Letter VIS-35 Date 07/01/06 603 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description Ophthalmological Services Provided During an E/M Visit, New or Established Patient 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient 92004 comprehensive, new patient, one or more visits 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient 92014 comprehensive, established patient, one or more visits 92015 Determination of refractive state CONSULTATIONS 99241 Office consultation for a new or established patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making 99242 Office consultation for a new or established patient, which requires these three key components: - an expanded problem-focused history; - an expanded problem-focused examination; and - straightforward medical decision making 99243 Office consultation for a new or established patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of low complexity 99244 Office consultation for a new or established patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity 99245 Office consultation for a new or established patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99251 Initial inpatient consultation for a new or established patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making