Or. Admin. Code § 410-140-0160 - Contact Lens Services and Supplies

(1) The following is general information regarding the Division's contact lens services and supplies coverage for members who receive services on an FFS basis:

(a) The prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation, is only covered when provided by an optometrist or other qualified physician. Contact lens fitting by an independent technician in an optometry office is not a covered service; and

(b) Contact lenses shall be billed to the Division at the provider's acquisition cost. Acquisition cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer or supplier plus any shipping fees for the item. Payment for contact lenses is the lesser of the Division fee schedule and acquisition cost.

(2) Coverage for eligible adults (age 21 or older):

(a) PA is required for contact lenses for adults (age 21 and older), except for a primary keratoconus diagnosis;

(b) Contact lenses for adults (age 21 and older) are covered only when one of the following conditions exists:

(A) Refractive error which is 9 diopters or greater in any meridian;

(B) Keratoconus;

(C) Anisometropia when the difference in power between two (2) eyes is 3 diopters or greater;

(D) Irregular astigmatism;

(E) Aphakia; or

(F) Post keratoplasty (e.g., corneal transplant), when medically necessary and within one (1) year of procedure.

(c) Prescription and fitting of contact lenses is limited to once every twenty four (24) months. Replacement of contact lenses is limited to a total of two (2) contacts every twelve (12) months (or the equivalent in disposable lenses) and does not require PA.

(3) Coverage for Children (birth through age 20):

(a) Contact lenses for children are covered and are not limited when it is documented in the clinical record that glasses may not be worn for medical reasons, including, but not limited to:

(A) Refractive error which is 9 diopters or greater in any meridian;

(B) Keratoconus;

(C) Anisometropia when the difference in power between two (2) eyes is 3 diopters or greater;

(D) Irregular astigmatism; or

(E) Aphakia.

(b) Replacement of contact lenses is covered when documented as medically appropriate in the clinical record and does not require PA.

(4) Contact lenses for treatment of disease or trauma (e.g., corneal bandage lens) are inclusive of the fitting. Follow up visits to determine eye health status may be separately reimbursed when the trauma or disease is clearly documented in the member record.

(5) An extra or spare pair of contacts is not covered.

(6) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

Notes

Or. Admin. Code § 410-140-0160

AFS 75-1989, f. & cert. ef. 12-15-89; HR 15-1992, f. & cert. ef. 6-1-92, Renumbered from 461-018-0230; HR 37-1992, f. & cert. ef. 12-18-92; HR 5-1995, f. & cert. ef. 3-1-95; HR 1-1996, f. 1-12-96, cert. ef. 1-15-96; OMAP 20-1999, f. & cert. ef. 4-1-99; OMAP 24-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 11-2002, f. & cert. ef. 4-1-02; OMAP 65-2004, f. 9-13-04, cert. ef. 10-1-04; DMAP 21-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 20-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 44-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14; DMAP 7-2016, f. 2-23-16, cert. ef. 3/1/2016; DMAP 19-2021, temporary amend filed 05/13/2021, effective 05/13/2021 through 11/08/2021; DMAP 45-2021, amend filed 10/22/2021, effective 10/22/2021; DMAP 51-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 127-2024, amend filed 10/08/2024, effective 10/8/2024; DMAP 148-2024, minor correction filed 12/29/2024, effective 12/29/2024

Tables referenced are available from the agency.

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & 414.065