New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 4 - Fees and Reimbursement › Part 537 - State Reimbursement For Optometric Services › Section 537.4 - Reimbursement for payments to dispensing opticians and other retail optical establishments

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 The maximum reimbursable allowance for services of dispensing opticians and
			 other retail optical establishments (including salaried optometrists employed
			 by retail optical establishments) shall be as follows:
FEES FOR LENSES AND FRAMES
First or single pair of eyeglasses
Code
Item
Fee
Remarks
2
E601
Single vision, standard chart thickness
**
1
E651
hardening and testing *
$2.22
E661
tinting
**
prior approval
E701
Single vision, over-standard chart thickness
**
prior approval
E751
hardening and testing *
$3.70
prior approval
E761
tinting
**
prior approval
E801
Bifocals
**
E851
hardening and testing *
$4.00
E861
tinting
**
prior approval
E901
Trifocals
**
E951
hardening and testing *
$4.44
E961
tinting
**
prior approval
E521
Frame, wholesale cost up to $4.00
**
E621
Frame, wholesale cost more than $4.00
**
prior approval
1 Prior approval required if
			   correction is less than 1/2 diopter.
* Hardening, testing and
			   markup (48%) included in this fee.
** Reimbursement at actual
			   wholesale cost to the dispenser plus 48 percent above such cost. The following
			   amounts will be accepted as minimum wholesale costs in computing the
			   markup.
Single vision lenses and frames
			   $5.50...............................
Bifocal lenses and frames
			   8.00.....................................................
Trifocal lenses and frames
			   13.00..........................................................
2 Remarks applicable only in
			   the medical assistance program.
Second pair of eyeglasses (dispensed at same
			   time)
Code
Item
Fee
Remarks
2
E602
Single vision, standard chart thickness
**
E652
hardening and testing *
$2.22
E662
tinting
**
prior approval
E702
Single vision, overstandard chart thickness
**
prior approval
E752
hardening and testing *
$3.70
prior approval
E762
tinting
**
prior approval
E522
Frame, wholesale cost up to $4.00
**
E622
Frame, wholesale cost more than $4.00
**
prior approval
FEES FOR OTHER
					   SERVICES
E500
Examination by a salaried optometrist 3 to include
					 diagnosis for optical deficiency and for visual or musclar anomaly of the human
					 eye
$5.004
E503
Contact lenses-provided for ocular pathology only
					 and recommended by an ophthalmologist
by report
prior approval
E571
Adjustment by other than original provider
$2.00
E581
Repair for replacement of broken parts (wholesale
					 cost plus 60 percent markup over wholesale cost) minimum of
$2.00
* Hardening, testing and
			   markup (48%) included in this fee.
** Reimbursement at actual
			   wholesale cost to the dispenser plus 48 percent above such cost. The following
			   amounts will be accepted as minimum wholesale costs in computing the
			   markup.
Single vision lenses and frames $5.50
Bifocal lenses and frames 8.00....................
Trifocal lenses and frames
			   13.00.......................
2 Remarks applicable only in
			   the medical assistance program.
3 "Salaried optometrist" means
			   a qualified optometrist employed by either a retail optical establishment or
			   dispensing optician or a non-profit health service corporation as defined in
			   article IX-C of the State Insurance Law.
4 The eye examination provided
			   by a qualified salaried optometrist to be accepted as the basis for
			   prescription of eyeglasses shall include, as a minimum, the components of an
			   optometric examination contained in section
			   505.6  of the
			   Title. Eye examinations which do not meet this standard will not be considered
			   acceptable for purposes of payment from funds under public tax-supported
			   medical care programs. Payment of this fee is effective August 1,
			   1975.
(b) The fees provided
			 herein (including markup) are intended to cover all services performed by the
			 above providers in connection with the dispensing of eyeglasses and will be
			 considered full payment for services rendered under State-administered
			 programs. Under the medical assistance program, which is administered by local
			 social services districts, these fees (including markup) represent a maximum
			 allowance for purposes of State reimbursement.
(c) Need for two pairs of eyeglasses, one
			 pair for distance and one for near vision, should be uncommon. Such dispensing
			 must be substantiated by the patient's particular needs, such as proven
			 inability to tolerate bifocals, the unusual nature of the patient's correction,
			 physical ailments, and other conditions which make provision of bifocals
			 inadvisable. Two pairs of eyeglasses should not be provided merely as an
			 alternative to bifocals to satisfy an unjustificable preference on the part of
			 the patient, for personal convenience or for cosmetic purposes.
(d) The following standards shall be observed
			 in providing lenses and frames.
(1) In all
			 claims for payment, the model or style, name, catalog number and name of
			 manufacturer of the lenses and frames supplied must be included.
(2) All lenses, frames and frame parts shall
			 be guaranteed against defects in manufacture or assembly.
(3) Billing may be based on wholesale
			 prescription assembled cost, regardless of origin of finished
			 services.
(4) All claims for
			 payment are subject to audit which must include verification of wholesale
			 costs.
(5) Only first quality
			 frames shall be supplied. The dispenser shall be responsible for any needed
			 replacement or repairs that are due to defects in quality or material or
			 workmanship.
(6) Frames provided
			 shall not exceed a wholesale cost of four dollars except, that for clinical
			 reasons documented by the prescribing ophthalmologist or optometrist, a more
			 expensive frame may be approved for an individual. Such exceptions require
			 prior approval by the appropriate medical director and prior authorization by
			 the social services commissioner.
(7) No extra charge shall be made by a
			 dispenser of eyeglasses for future fittings and adjustments if he has dispensed
			 the eyeglasses. Provision for this service has been included in the above
			 fee.