Sec. 10.09.14.04. Covered Services

A. The program covers the following vision care services:

(1) A maximum of one optometric examination every 2 years for recipients 21 years old or older and a maximum of one every year for recipients younger than 21 years old, to determine the extent of visual impairment or the correction required to improve visual acuity, unless the time limitations are waived by the Department, based on medical necessity;

(2) Subject to §B, of this regulation, a maximum of one pair of eyeglasses every year, unless the time limitations are waived by the Department, based on medical necessity;

(3) Examination and eyeglasses for a recipient with a medical condition, other than normal physiological change necessitating a change in eyeglasses (before the normal time limits specified in §§A and B of this regulation have been met) when a preauthorization has been procured;

(4) Visually necessary optometric care rendered by an optometrist when these services are:

(a) Provided by the optometrist or a licensed employee;

(b) Related to the patient's health needs as diagnostic, preventive, curative, palliative, or rehabilitative services; and

(c) Adequately described in the patient's record; and

(5) Optician services when the services are:

(a) Provided by the optician, optometrist, or ophthalmologist, or by an employee under the optician's, optometrist's, or ophthalmologist's supervision and control;

(b) Adequately described in the patient's record;

(c) Ordered or prescribed by an ophthalmologist or optometrist.

B. Eyeglasses.

(1) The eyeglasses under §A(2) of this regulation shall have first quality, impact resistant lenses, except in cases where prescription requirements cannot be met with impact resistant lenses. Frames shall be made of fire-resistant, first-quality material.

(2) In order to be entitled to receive eyeglasses under §A(2) of this regulation, a recipient shall meet at least one of the following conditions:

(a) The recipient requires a diopter change of at least 0.50;

(b) The recipient requires a diopter correction of less than 0.50 and this has been preauthorized according to Regulation .06, of this chapter, based on medical necessity;

(c) The recipient's present eyeglasses have been damaged to the extent that they affect visual performance and cannot be repaired to effective performance standards, or are no longer usable due to a change in head size or anatomy; or

(d) The recipient's present eyeglasses have been lost or stolen.