Vision Services Coverage and Limitations
(1)Providers shall comply with the following rules in addition to the Visual Services program rules to determine service coverage and limitations for OHP clients according to their benefit packages:
(a)General Rules (OAR chapter 410, division 120);
(b)OHP administrative rules (410-141-0480, 410-141-0500, and 410-141-0520);
(c)Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (List) (OAR 410-141-0520); and
(d)Referenced guideline notes (The date of service determines the correct version of the administrative rules and HERC List to determine coverage.); and
(e)The Authority’s general rules related to provider enrollment and claiming (OAR 943-120-0300 (Definitions) through 1505).
(2)The Division covers ocular prosthesis (e.g., artificial eye) and related services. See OAR 410-122-0640 (Eye Prostheses) Eye Prostheses for service coverage and limitations.
(3)The Division covers reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the HERC List. Once a diagnosis is established for a service, treatment, or item that falls below the funding line, the Division may not cover any other service related to the diagnosis.
(4)Coverage for eligible adults (age 21 and older):
(a)Diagnostic evaluations and medical examinations are not limited if documentation in the physician’s or optometrist’s clinical record justifies the medical need;
(b)Ophthalmological intermediate and comprehensive exam services are not limited for medical diagnosis;
(c)Vision therapy is not covered; and
(d)Visual services for the purpose of prescribing glasses or contact lenses, fitting fees, or glasses or contact lenses:
(A)One complete examination and determination of refractive state is limited to once every 24 months for pregnant adult women;
(B)Non-pregnant adults are not covered, except when the client:
(i)Has a medical diagnoses of aphakia, pseudoaphakia, congenital aphakia, keratoconus; or
(ii)Lacks the natural lenses of the eye due to surgical removal (e.g., cataract extraction) or congenital absence; or
(iii)Has had a keratoplasty surgical procedure (e.g., corneal transplant) with limitations described in OAR 410-140-0160 (Contact Lens Services and Supplies) (Contact Lens Services and Supplies); and
(iv)Is limited to one complete examination and determination of refractive state once every 24 months.
(5)OHP Plus Children (birth through age 20):
(a)All ophthalmological examinations and vision services, including routine vision exams, fittings, repairs, and materials are covered when documentation in the clinical record justifies the medical need;
(b)Orthoptic and pleoptic training or “vision therapy” is:
(A)Covered when therapy treatment pairs with a covered diagnosis on the HERC List;
(B)Limited to six sessions per calendar year without PA:
(i)The initial evaluation is included in the six therapy sessions;
(ii)Additional therapy sessions require PA (OAR 410-140-0040 (Prior Authorization));
(C)Shall be provided pursuant to OAR 410-140-0280 (Vision Therapy Services) (Vision Therapy).
(6)Refraction determination is not limited following a diagnosed medical condition (e.g., multiple sclerosis).
Rule 410-140-0140 — Vision Services Coverage and Limitations,