CABINET FOR HEALTH AND FAMILY SERVICES

Department for Medicaid Services

Division of Policy and Operations

(As Amended at ARRS, May 13, 2014)

 

††††† 907 KAR 1:631.[Reimbursement of] Vision Program reimbursement provisions and requirements[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 to qualify for federal Medicaid funds[for the provision of medical assistance to Kentucky's indigent citizenry]. This administrative regulation establishes Medicaid Program reimbursement provisions and requirements for vision services provided to a Medicaid recipient who is not enrolled in a managed care organization[provisions for vision services].

 

††††† Section 1. Definitions. (1) "CPT code" means a code used for reporting procedures and services performed by medical practitioners and published annually by the American Medical Association in Current Procedural Terminology.

††††† (2) "Department" means the Department for Medicaid Services or its designee[designated agent].

††††† (3)[(2)] "Enrollee" means a recipient who is enrolled with a managed care organization.

††††† (4)[(3)] "Federal financial participation" is defined by 42 C.F.R. 400.203.

††††† (5)[(4)] "Healthcare Common Procedure Coding System" or "HCPCS" means a collection of codes acknowledged by the Centers for Medicare and Medicaid Services (CMS) that represents[represent] procedures or items.

††††† (6)[(5)] "Managed care organization" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined in 42 C.F.R. 438.2.

††††† (7)[(4)] ["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.

††††† (8)[(7)][(4)] "Ophthalmic dispenser" means an individual who is qualified to engage in the practice of ophthalmic dispensing in accordance with KRS 326.030 or 326.040.

††††† (9)[(8)] "Optometrist" means an individual who is licensed as an optometrist in accordance with KRS Chapter 320[is defined by KRS 311.271].

††††† (10)[(9)] "Provider" is defined by KRS 205.8451(7).

††††† (11)[(10)] "Recipient" is defined by KRS 205.8451(9).

††††† (12) ďUsual and customary chargeĒ means the uniform amount the provider charges in the majority of cases for the service or item[205.8541(9)][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. General Requirements. (1)[(a)] For the department to reimburse for a vision service or item, the requirements established in 907 KAR 1:632 and this administrative regulation shall be met.

††††† (2)[service or item shall be:

††††† 1. Provided:

††††† a. To a recipient; and

††††† b. By a provider who:

††††† (i) Is enrolled in the Medicaid Program pursuant to 907 KAR 1:672;

††††† (ii) Except as established in paragraph (b) of this subsection, is currently participating in the Medicaid Program pursuant to 907 KAR 1:671; and

††††† (iii) Is authorized by this administrative regulation to provide the given service or item;

††††† 2. Covered in accordance with 907 KAR 1:632;

††††† 3. Medically necessary;

††††† 4. A service or item authorized within the scope of the providerís licensure; and

††††† 5. A service or item listed on the Department for Medicaid Services Vision Program Fee Schedule.

††††† (b) In accordance with 907 KAR 17:010, Section 3(3), a provider of a service to an enrollee shall not be required to be currently participating in the Medicaid Program if the managed care organization in which the enrollee is enrolled does not require the provider to be currently participating in the Medicaid Program.

††††† (2)(a) To be recognized as an authorized provider of visions services, an optometrist shall:

††††† 1. Be certified by the:

††††† a. Kentucky Board of Optometric Examiners; or

††††† b. Optometric examiner board of the state in which the optometrist practices if the optometrist practices in a state other than Kentucky;

††††† 2. Submit to the department proof of licensure upon initial enrollment in the Kentucky Medicaid Program; and

††††† 3. Annually submit to the department proof of licensure renewal including the expiration date of the license and the effective date of renewal.

††††† (b)1. To be recognized as an authorized provider of vision services, an in-state optician shall:

††††† a. Hold a current license in Kentucky as an ophthalmic dispenser;

††††† b. Comply with the requirements established in KRS Chapter 326;

††††† c. Submit to the department proof of licensure upon initial enrollment in the Kentucky Medicaid Program; and

††††† d. Annually submit to the department proof of licensure renewal including the expiration date of the license and the effective date of renewal.

††††† 2. To be recognized as an authorized provider of vision services, an out-of-state optician shall:

††††† a. Hold a current license in the state in which the optician practices as an ophthalmic dispenser;

††††† b. Submit to the department proof of licensure upon initial enrollment in the Kentucky Medicaid Program; and

††††† c. Annually submit to the department proof of licensure renewal including the expiration date of the license and the effective date of renewal.

††††† (3)](a) If a procedure is part of a comprehensive service, the department shall:

††††† 1. Not reimburse separately for the procedure; and

††††† 2. Reimburse one (1) payment representing reimbursement for the entire comprehensive service.

††††† (b) A provider shall not bill the department multiple procedures or procedural codes if one (1) CPT code or HCPCS code is available to appropriately identify the comprehensive service provided.

††††† (3)[(4) A provider shall comply with:

††††† (a) 907 KAR 1:671;

††††† (b) 907 KAR 1:672; and

††††† (c) All applicable state and federal laws.

††††† (5)](a) If a provider receives any duplicate payment or overpayment from the department, regardless of reason, the provider shall return the payment to the department.

††††† (b) Failure to return a payment to the department in accordance with paragraph (a) of this subsection may be:

††††† 1. Interpreted to be fraud or abuse; and

††††† 2. Prosecuted in accordance with applicable federal or state law.

††††† [(c) Nonduplication of payments and third-party liability shall be in accordance with 907 KAR 1:005.

††††† (d) A provider shall comply with KRS 205.622.]

††††† (4)[(6)] The department shall not reimburse for:

††††† (a) A service with a CPT code that is not listed on the Department for Medicaid Services Vision Program Fee Schedule; or

††††† (b) An item with an HCPCS code that is not listed on the Department for Medicaid Services Vision Program Fee Schedule.

 

††††† Section 3. Reimbursement for Covered Procedures and Materials for Optometrists. (1) Except for[With the exception of materials or] a clinical laboratory service, the departmentís reimbursement for a covered service or covered item provided by a participating optometrist[, within the optometrist's scope of licensure,] shall be the lesser of the:

††††† (a) Optometristís usual and customary charge for the service or item; or

††††† (b) Reimbursement established on the Department for Medicaid Services Vision Program Fee Schedule for the service or item.

††††† (2) The department shall reimburse for a covered clinical laboratory service in accordance with 907 KAR 1:028[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 4.[3.] Maximum Reimbursement for Covered Procedures and Materials for Ophthalmic Dispensers. The departmentís reimbursement for a covered service or covered item provided by a participating ophthalmic dispenser[within the ophthalmic dispenser's scope of licensure] shall be the lesser of the:

††††† (1) Ophthalmic dispenserís usual and customary charge for the service or item; or

††††† (2) Reimbursement established on the Department for Medicaid Services Vision Program Fee Schedule for the service or item[in accordance with Section 2 of this administrative regulation].

 

††††† Section 5.[4.] Reimbursement Limitations. (1) The department shall not reimburse for:

††††† (a) A telephone consultation;

††††† (b)[shall be excluded from payment.

††††† (2)] Contact lenses, except as established in 907 KAR 1:632, Section 5(1);

††††† (c)[shall be excluded from payment.

††††† (3)] Safety glasses unless[shall be covered if] proof of medical necessity is documented;

††††† (d)[.

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

††††† (5)] A press-on prism; or

††††† (e) A service with a CPT code or item with an HCPCS code that is not listed on the Department for Medicaid Services Vision Program Fee Schedule[shall be excluded from payment].

††††† (2)(a) The department shall reimburse for no more than one (1) pair of eyeglasses per recipient per calendar year[twelve (12) consecutive month period] unless:

††††† 1. The recipientís eyeglasses are broken or lost during the calendar year[twelve (12) consecutive month period]; or

††††† 2. The eyeglass prescription for the recipient is changed during the calendar year[twelve (12) consecutive month period].

††††† (b) If an event referenced in paragraph (a)1 or 2 of this subsection occurs within the calendar year[twelve (12) consecutive month period], the department shall reimburse for one (1) additional pair of eyeglasses for the recipient during the calendar year[twelve (12) consecutive month period].

††††† (3) A prism, if medically necessary, shall be included in the cost of lenses.

 

††††† Section 6.[5.] Third Party Liability. (1) Nonduplication of payments and third-party liability shall be in accordance with 907 KAR 1:005.

††††† (2) A provider shall comply with KRS 205.622.

 

††††† Section 7. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse the same amount as established in this administrative regulation for an item or service reimbursed by the department via this administrative regulation.

 

††††† Section 8. Federal Approval and Federal Financial Participation. The departmentís reimbursement for services pursuant to this administrative regulation shall be contingent upon:

††††† (1) Receipt of federal financial participation for the reimbursement; and

††††† (2) Centers for Medicare and Medicaid Servicesí approval for the reimbursement.

 

††††† Section 9.[6.] Appeal Rights. A provider may appeal a department decision as to the application of this administrative regulation[(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.

 

††††† Section 10. Incorporation by Reference. (1) "Department for Medicaid Services Vision Program Fee Schedule", May 13,[April] 2014[December 2013], is incorporated by reference.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the departmentís Web site at http://www.chfs.ky.gov/dms/incorporated.htm.

 

LAWRENCE KISSNER, Commissioner

AUDREY TAYSE HAYNES, Secretary

††††† APPROVED BY AGENCY: March 28, 2014

††††† FILED WITH LRC: March 31, 2014 at 3 p.m.

††††† CONTACT PERSON: Tricia Orme, email tricia.orme@ky.gov, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573.