N.J. Admin. Code § 10:62-2.4 - Covered optical appliances and related services

Current through Register Vol. 54, No. 7, April 4, 2022

(a) The following optical appliances and related services are covered under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs. In order to determine whether an optical appliance or related service requires prior authorization, and for details regarding such prior authorization, see N.J.A.C. 10:62-2.5.
1. Optical lenses (see 10:62-2.6 );
2. Optical frames (see 10:62-2.7 );
3. Repairs of optical appliances;
4. Artificial eyes may be provided once every three years when prescribed by an ophthalmologist or an optometrist;
5. Low vision devices;
6. Vision training devices;
7. Replacement of optical appliances:
i. Lenses and frames may be replaced once every two years for persons age 19 through and including 59 years of age, and once a year for persons less than 19 years or 60 years of age and older, provided there is a change of 0.50 diopter in sphere and or cylinder power, or a change of five degrees or more in cylinder axis.
ii. Lenses may be replaced more frequently than once every two years for persons 19 through and including 59 years of age or more frequently than once every year for persons less than 19 years or 60 years of age and older, providing there is a prescription change of at least 0.75 diopter in spherical and/or cylindrical power or a change in axis of eight degrees or more. Providers shall enter the previous prescription number in the Remarks section (#19) of the MC-9 claim form.
iii. When an optical appliance is destroyed in a fire or stolen, the provider shall place a written statement in the Remarks section (#19) of the MC-9 claim form and put a copy of the fire/police report in the provider's beneficiary's file.
iv. Providers may provide one replacement of frame and/or lenses per year for individuals with developmental disabilities. Provider shall place a written supporting statement and diagnosis related information in the Remarks section (#19) of the MC-9 claim form and put a copy of the developmental disabilities report in the provider's beneficiary's file.
v. Contact lenses will be provided once every two years for persons age 19 through and including 59 years of age, and once a year for persons up to age 19 or 60 years of age and older.
(1) Replacement of a contact lens in less than the timeframes in this subparagraph is allowed only if there is a need for a change in the fit or design of the lens or if there has been a prescription change of 0.50 diopter in spherical or astigmatic power. The need for a replacement due to a change in the fit or design of the lens shall be determined by the vision care professional based on an examination of the patient.
8. Dual pairs of glasses instead of multifocal;
9. Contact lenses;
10. Polycarbonated or ultraviolet filter lenses, when recommended by the prescribing practitioner as medically necessary;
11. Intraocular lenses; and
12. Protective prescription eyewear that is needed by a specific child beneficiary because it is required pursuant to N.J.S.A. 5:18-1 while the child participates in sports.

Notes

N.J. Admin. Code § 10:62-2.4
Amended by 49 N.J.R. 2279(b), effective 7/17/2017

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