Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth

Table of Contents iv

Provider Manual Series

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

4. Program Regulations

130 CMR 402.000: Vision Care Services

402.401: Introduction ............................................................................................................. 4-1 402.402: Definitions .............................................................................................................. 4-1 402.403: Eligible Members .................................................................................................... 4-2 402.404: Provider Eligibility .................................................................................................. 4-2 402.405: Nonreimbursable Circumstances ............................................................................ 4-3 432.406: Maximum Allowable Fees ...................................................................................... 4-4 402.407: Individual Consideration ........................................................................................ 4-4 402.408: Prior Authorization ................................................................................................. 4-4 402.409: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) ..................... 4-5 (130 CMR 402.410 through 402.415 Reserved) 402.416: Prescription and Dispensing Requirements ............................................................ 4-6 402.417: Recordkeeping Requirements ................................................................................. 4-7 402.418: Services Provided Outside the Office ..................................................................... 4-8 (130 CMR 402.419 through 402.425 Reserved) 402.426: Service Limitations: Eye Examinations ................................................................. 4-9 402.427: Service Limitations: Dispensing Eyeglasses ......................................................... 4-9 402.428: Service Limitations: Replacement Eyeglasses ................................................... 4-10 402.429: Service Limitations: Tinted Lenses .................................................................... 4-11 (130 CMR 402.430 Reserved) 402.431: Service Limitations: Two Pairs of Eyeglasses Instead of Bifocals ....................... 4-12 (130 CMR 402.432 Reserved) 402.433: Service Limitations: Contact Lenses .................................................................... 4-13 402.434: Service Limitations: Extra or Spare Eyeglasses ................................................... 4-13 402.435: Service Exclusions ................................................................................................. 4-13

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-1

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

402.401: Introduction

(A) 130 CMR 402.000 states the requirements and procedures for vision care services under MassHealth. Professional and technical services must be provided in accordance with the established standards of quality and health-care necessity recognized by the vision care industry and licensing agencies in Massachusetts.

(B) All vision care providers participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 402.000 and 130 450.000: Administrative and Billing Regulations.

402.402: Definitions

The following terms used in 130 CMR 402.000 have the meanings given in 130 CMR 402.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 402.402 is not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 402.000 and in 130 CMR 450.000: Administrative and Billing Regulations.

Date of Service – the date of service for dispensing vision care materials is the date on which the vision care materials are delivered to the member. The date of service for fitting vision care materials is the date that the order for materials was placed. The date of service for all other vision care services is the date on which the service is provided to the member.

Dispensing Practitioner – any licensed optician, licensed optometrist, licensed ophthalmologist, or other licensed participating provider authorized by the MassHealth agency to dispense eyeglass frames, lenses, and other ophthalmic materials to members.

Optical Supplier – the optical laboratory contracted by the MassHealth agency to supply the following ophthalmic materials and services:

(1) eyeglass frames;

(2) eyeglass lenses;

(3) frame cases;

(4) tints, coatings, ground-on prisms, and prisms by decentration; and

(5) repair or replacement parts.

Order – the process by which a dispensing practitioner requests ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier.

Prescriber – any optometrist, ophthalmologist, or other practitioner licensed and authorized to write prescriptions for eyeglass frames, lenses, and other vision care services.

Vision Care Provider – a health care practitioner or facility licensed to perform and provide appropriate vision care services in compliance with 130 CMR 402.000 and 450.000: Administrative and Billing Regulations.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-2

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

Vision Care Services – the professional care of the eyes to examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures. These services include eye examinations, vision training, managing and treating complex eye and vision problems, and the prescription and dispensing of ophthalmic materials.