Promoting and protecting the health and safety of all Idahoans
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Vision Services
Update
Recent legislation has directed changes to Medicaid optometry and vision services. These changes take effect July 1, 2011, and are described briefly in Medicaid Information Release MA11-11. The revised Vision Prior Authorization Request and Contact Lens Request Forms are now posted. Please utilize these forms when faxing requests to the Medical Care Unit beginning July 1, 2011.
Examinations and other vision services for adults age 21 and older will only be covered when they are necessary to treat or monitor a chronic condition that impacts overall health or that progressively degrades vision. Examples of such conditions include:
- Diabetes
- Macular Degeneration
- Sarcoidosis
- Glaucoma
- Cataracts
- Multiple Sclerosis
- Systemic Lupus Erythematosus
- Sjogren’s Syndrome
- Keratoconus
- Salzmann Nodules
Frames, conventional lenses, and contact lenses for the purposes of correcting nearsightedness, farsightedness, astigmatism, or other routine vision corrections will no longer be covered for adults age 21 and older.
- If eyeglasses or contacts are necessary to treat a chronic condition or prevent progressive degradation of vision, they will be covered with prior authorization.
- In such cases, providers should submit a letter of medical necessity documenting the chronic disease related need for contacts or eyeglasses with their prior authorization request.
Removal of foreign bodies, repairs of lacerations and other treatment for acute conditions that would result in permanent or chronic damage to the eye if left untreated will continue to be covered.
Providers should bill all vision services for adults age 21 and over with a diagnosis code to indicate the chronic condition requiring those services.
Coverage for participants under age 21 is not affected by these changes.
If you have questions about the changes in vision benefits, please contact the policy subject matter expert for the Division of Medicaid at (208) 364-1897 or by email to sirokyj@dhw.idaho.gov. Idaho Medicaid Vision Services are provided on a fee for service basis from local ophthalmologists, optometrists, and opticians. Contacts (when authorized) and eyeglasses are provided through a contract with Barnett and Ramel Optical.
The Medicaid Medical Care Unit is responsible for monitoring this contract and for reviewing and authorizing prescriptions for selected vision products and procedures. Click on the links at right to learn more about the vision review and prior authorization process.
For questions about the contract with Barnett & Ramel Optical, contact (208) 287-1177.
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