The MassHealth agency pays for two pairs of eyeglasses instead of bifocals if one or more of the following conditions exists. Any condition listed below that warrants the use of two pairs of eyeglasses instead of bifocals must be fully documented in the member's medical record.

1. (A) The member's prescription cannot satisfactorily be made into bifocal lenses.
2. (B) The member has shown an inability to adjust to bifocals.
3. (C) The member has a physical disability or medical condition (for example, severe arthritis) that would preclude or impede adjustment to bifocals.
4. (D) The member's advanced age would make adjustment to bifocals unduly difficult.
5. (E) The member's occupation would make bifocals hazardous.
6. (F) The member has a marked facial asymmetry.

(130 CMR 402.432 Reserved)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-13

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

402.433: Service Limitations: Contact Lenses

1. (A) The MassHealth agency pays for hard, soft, or gas-permeable contact lenses if one or more of the following conditions exists:

   1. (1) postoperative cataract extraction;
   2. (2) keratoconus;
   3. (3) anisometropia of more than 3.00D; or
   4. (4) more than 7.00D of myopia or hyperopia.
2. (B) The MassHealth agency pays for therapeutic contact lenses when medically necessary.
3. (C) Any condition that warrants the use of hard, soft, gas-permeable, or therapeutic contact lenses must be fully documented in the member's medical record.

402.434: Service Limitations: Extra or Spare Eyeglasses

The MassHealth agency pays for an extra or spare pair of eyeglasses on a prior authorization basis only. Any condition that warrants the use of an extra or spare pair of eyeglasses must be fully documented in the member's medical record. The MassHealth agency grants a prior authorization request for extra or spare eyeglasses only if one or more of the following conditions exists:

1. (A) aphakia;
2. (B) more than 7.00D of myopia or hyperopia; or
3. (C) more than 3.00D of astigma.

402.435: Service Exclusions

1. (A) The MassHealth agency does not pay for any of the following services or materials:

   1. (1) absorptive lenses of greater than 25% absorption;
   2. (2) prisms obtained by decentration;
   3. (3) non-medical interventions;
   4. (4) routine adjustments or follow-up visits to check visual acuity and ocular comfort (payment for such visits is included in the dispensing fee for six months after the date on which the eyeglasses were dispensed);
   5. (5) contact lenses for extended-wear use;
   6. (6) invisible bifocals/no line progressive lenses; and
   7. (7) substitutions.
2. (B) (1) If a member desires a substitute for, or a modification of, a reimbursable item, such as designer frames, the member must pay for the entire cost of the eyeglasses, including dispensing fees. The MassHealth agency does not pay for a portion of the cost of the eyeglasses. In all such instances, the provider must inform the member of the availability of reimbursable items before dispensing nonreimbursable items.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-14

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

1. (2) It is unlawful (M.G.L. c. 6A, § 35) for a provider to accept any payment from a member for a service or item for which payment is available under MassHealth. If a member claims to have been misinformed about the availability of reimbursable items, it will be the responsibility of the provider to prove that the member was offered a reimbursable item, refused it, and chose instead to accept and pay for a nonreimbursable item.

REGULATORY AUTHORITY

130 CMR 402.000: M.G.L. c. 118E, §§ 7 and 12.