Payment for services described in 130 CMR 402.000 will be made only to providers of vision care services who are participating in MassHealth on the date of service. The eligibility requirements for providers of vision care services are as follows.

1. (A) In State.

   1. (1) Optometrists. A Massachusetts optometrist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration in Optometry.

      1. (a) A Level I optometrist is one who is not qualified to apply topical agents.
      2. (b) A Level II optometrist is one who has obtained a Certificate of Qualification for the Use of Diagnostic Pharmaceutical Agents (DPAs) from the Board of Registration in Optometry.
      3. (c) A Level III optometrist is one who has obtained a Certificate of Qualification for the Use of Therapeutic Pharmaceutical Agents (TPAs) from the Board of Registration in Optometry.
   2. (2) Opticians. A Massachusetts optician is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration of Opticians.
   3. (3) Ophthalmologists. A Massachusetts ophthalmologist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration in Medicine. An ophthalmologist is governed by 130 CMR 402.000 only with respect to the dispensing of ophthalmic materials. All other vision care services provided by an ophthalmologist must be in compliance with 130 CMR 433.000: Physician Services.
   4. (4) Ocularists. A Massachusetts ocularist is eligible to participate in MassHealth only if certified by the National Examining Board of Ocularists.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

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1. (5) Acute Hospital Outpatient Departments and Hospital-licensed Health Centers and Other Satellite Clinics. An acute hospital outpatient department or hospital-licensed health center or other satellite clinic that participates in MassHealth pursuant to the Executive Office of Health and Human Services (EOHHS) Acute Hospital Request for Applications (RFA) and contract is eligible to provide services under 130 CMR 402.000. Acute hospital outpatient departments and hospital-licensed health centers or other satellite clinics are paid pursuant to 130 CMR 402.000 for services described as ophthalmic materials dispensing in Subchapter 6 of the Vision Care Manual. All other vision care services provided by an acute hospital outpatient department or hospital-licensed health center or other satellite clinic are paid in accordance with the RFA and contract.
2. (6) Community Health Center. A community health center with a current provider agreement with EOHHS for the provision of community health center services is eligible to provide services under 130 CMR 402.000. Community health centers are paid pursuant to 130 CMR 402.000 for services described as ophthalmic materials dispensing in Subchapter 6 of the Vision Care Manual. All other vision care services provided by a community health center are paid in accordance with the community health center regulations at 130 CMR 405.000: Community Health Center Services.

3. (B) Out of State.

   1. (1) Optometrists. An optometrist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the optometrist is licensed to practice by the appropriate state's board of registration.
   2. (2) Opticians. An optician located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the optician is licensed to practice by the appropriate state's board of registration.
   3. (3) Ophthalmologists. An ophthalmologist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ophthalmologist is licensed to practice by the appropriate state's board of registration. An ophthalmologist is governed by 130 CMR 402.000 only with respect to the dispensing of ophthalmic materials. All other vision care services provided by ophthalmologists must be in compliance with 130 CMR 433.000: Physician Services.
   4. (4) Ocularists. An ocularist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ocularist has been certified by the National Examining Board of Ocularists.

402.405: Nonreimbursable Circumstances

With the exception of the dispensing of ophthalmic materials, vision care services are not reimbursable to a vision care provider under 130 CMR 402.000 when the services are furnished in a state institution, in an acute inpatient hospital setting, or when the services are among those for which the provider is otherwise compensated by the state or institution.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-4

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

402.406: Maximum Allowable Fees

The Executive Office of Health and Human Services (EOHHS) determines the maximum allowable fees for all vision care services and ophthalmic materials, except for those ophthalmic materials purchased through the optical supplier where the basis for the rates is set by the terms of the contract. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 402.000 and 130 CMR 450.000: Administrative and Billing Regulations. Payment for vision care services and ophthalmic materials will be made pursuant to 101 CMR 315.00: Rates for Vision Care Services and Ophthalmic Materials.

402.407: Individual Consideration

MassHealth has designated certain services in Subchapter 6 of the Vision Care Manual as requiring individual consideration. This means that the MassHealth agency will establish the appropriate rate for these services based on the standards and criteria set forth in 130 CMR 402.407(B). Providers claiming payment for any service requiring individual consideration must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that may include, but is not limited to, a descriptive report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for services requiring individual consideration unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim.

1. (A) The MassHealth agency determines the appropriate payment for a service requiring individual consideration in accordance with the following standards and criteria:

   1. (1) the amount of time required to perform the service;
   2. (2) the degree of skill required to perform the service;
   3. (3) the severity and complexity of the member's disease, disorder, or disability;
   4. (4) any applicable relative-value studies;
   5. (5) any complications or other circumstances that the MassHealth agency deems relevant;
   6. (6) the policies, procedures, and practices of other third-party insurers; and
   7. (7) for ophthalmic materials or supplies, a copy of the invoice from the supplier showing the actual acquisition cost.

402.408: Prior Authorization

1. (A) For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the Vision Care Manual with the abbreviation “P.A.” require prior authorization. These services include but are not limited to the following:

   1. (1) certain contact lenses;
   2. (2) low-vision aids;
   3. (3) unlisted services;
   4. (4) high-index lenses;
   5. (5) special-needs glasses;

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

1. (6) polycarbonate lenses for members aged 21 years of age or older, except for members who are amblyopic or monocular; and
2. (7) vision training.
3. (B) All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Vision Care Manual. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment.

402.409: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

The MassHealth agency pays for all medically necessary vision care services for EPSDT- eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 402.000, and with prior authorization.

(130 CMR 402.410 through 402.415 Reserved)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-6

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24