Section 107.20. Vision care services.

 

(1)   Covered services. Covered vision care services are eyeglasses and those medically necessary services provided by licensed optometrists within the scope of practice of the profession of optometry as defined in s. 449.01 , Stats., who are certified under s. DHS 105.32 , and by opticians certified under s. DHS 105.33 and physicians certified under s. DHS 105.05 .

(2)   Services requiring prior authorization. The following covered services require prior authorization by the department:

(a) Vision training, which shall only be approved for patients with one or more of the following conditions:

1. Amblyopia;

2. Anopsia;

3. Disorders of accommodation; and

4. Convergence insufficiency;

(b) Aniseikonic services for recipients whose eyes have unequal refractive power;

(c) Tinted eyeglass lenses, occupational frames, high index glass, blanks (55 mm. size and over) and photochromic lens;

(d) Eyeglass frames and all other vision materials which are not obtained through the MA vision care volume purchase plan;

(e) All contact lenses and all contact lens therapy, including related materials and services, except where the recipient's diagnosis is aphakia or keratoconus;

(f) Ptosis crutch services and materials;

(g) Eyeglass frames or lenses beyond the original and one unchanged prescription replacement pair from the same provider in a 12-month period; and

(h) Low vision services.

(3)   Other limitations.

(a) Eyeglass frames, lenses, and replacement parts shall be provided by dispensing opticians, optometrists and ophthalmologists in accordance with the department's vision care volume purchase plan. The department may purchase from one or more optical laboratories some or all ophthalmic materials for dispensing by opticians, optometrists or ophthalmologists as benefits of the program.

(b) Lenses and frames shall comply with ANSI standards.

(c) The dispensing provider shall be reimbursed only once for dispensing a final accepted appliance or component part.

(d) The department may define minimal prescription levels for lenses covered by MA. These limitations shall be published by the department in the MA vision care provider handbook.

(4)   Non-covered services. The following services and materials are not covered services:

(a) Anti-glare coating;

(b) Spare eyeglasses or sunglasses; and

(c) Services provided principally for convenience or cosmetic reasons, including but not limited to gradient focus, custom prosthesis, fashion or cosmetic tints, engraved lenses and anti-scratch coating.

Cr. Register, February, 1986, No. 362 , eff. 3-1-86; correction in (1) made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 .

Note

Under the department's vision care volume purchase plan, MA-certified vision care providers must order all eyeglasses and component parts prescribed for MA recipients directly from a supplier under contract with the department to supply those items. Microsoft Windows NT 6.1.7601 Service Pack 1 For more information on prior authorization, see s. DHS 107.02 (3) . Microsoft Windows NT 6.1.7601 Service Pack 1 For more information on non-covered services, see s. DHS 107.03 . Microsoft Windows NT 6.1.7601 Service Pack 1