(1) These requirements are in addition to the rule provisions generally applicable to Medicaid providers.
(2) The dispensing service may be provided by an ophthalmologist, an optometrist, an optician, or their employees within the scope of their professional practice allowed by law.
(3) Ophthalmologists, optometrists, opticians, or their employees dispensing eyeglasses and ophthalmologists or optometrists, or their employees dispensing contact lenses must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(4) A member under 21 years of age is limited to one pair of eyeglasses per 365-day period and a member 21 years of age or older is limited to one pair of eyeglasses every 730-day period.
(5) A member may receive additional lenses in the following circumstances:
(a) cataract surgery;
(b) .50 diopter change in correction in sphere;
(c) .75 diopter change in cylinder;
(d) .5 prism diopter change in vertical prism;
(e) .50 diopter change in the near reading power;
(f) a minimum of a 5 degree change in axis of any cylinder less than or equal to 3.00 diopters;
(g) a minimum of a 3 degree change in axis of any cylinder greater than 3.00 diopters; or
(h) any 1 prism diopter or more change in lateral prism.
(6) A member may obtain replacement lenses only 365 days after the existing eyeglasses were dispensed if the lenses are unusable.
(7) The following lens features are not covered:
(a) photochromatic or transition lenses;
(b) progressive lenses;
(c) ultraviolet coating;
(d) scratch resistant coating;
(e) anti-reflective coating;
(f) polycarbonate lenses except for monocular members; and
(g) tinted lenses except for rose 1 or rose 2.
(8) If a member is unable to wear bifocals because of a diagnosed medical condition and a provider requests an exception:
(a) a member under 21 years of age may be allowed two pairs of single vision eyeglasses every 365-day period; and
(b) a member 21 years of age and older may be allowed two pairs of single vision eyeglasses every 730-day period.
(9) Contact lenses may be provided only if medically necessary.
(a) The limits stated in (5) and (6) apply to contacts.
(b) The dispensing provider must receive prior authorization from the department for contact lenses and dispensing fee.