New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.4 - Covered optical appliances and related services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following optical appliances and related services are covered under the New
				Jersey Medicaid/NJ FamilyCare fee-for-service programs. In order to determine
				whether an optical appliance or related service requires prior authorization,
				and for details regarding such prior authorization, see
				N.J.A.C.
				10:62-2.5.
1. Optical lenses (see
				10:62-2.6 );
2. Optical frames (see
				10:62-2.7 );
3. Repairs of optical appliances;
4. Artificial eyes may be provided once every
				three years when prescribed by an ophthalmologist or an optometrist;
5. Low vision devices;
6. Vision training devices;
7. Replacement of optical appliances:
i. Lenses and frames may be replaced once
				every two years for persons age 19 through and including 59 years of age, and
				once a year for persons less than 19 years or 60 years of age and older,
				provided there is a change of 0.50 diopter in sphere and or cylinder power, or
				a change of five degrees or more in cylinder axis.
ii. Lenses may be replaced more frequently
				than once every two years for persons 19 through and including 59 years of age
				or more frequently than once every year for persons less than 19 years or 60
				years of age and older, providing there is a prescription change of at least
				0.75 diopter in spherical and/or cylindrical power or a change in axis of eight
				degrees or more. Providers shall enter the previous prescription number in the
				Remarks section (#19) of the MC-9 claim form.
iii. When an optical appliance is destroyed
				in a fire or stolen, the provider shall place a written statement in the
				Remarks section (#19) of the MC-9 claim form and put a copy of the fire/police
				report in the provider's beneficiary's file.
iv. Providers may provide one replacement of
				frame and/or lenses per year for individuals with developmental disabilities.
				Provider shall place a written supporting statement and diagnosis related
				information in the Remarks section (#19) of the MC-9 claim form and put a copy
				of the developmental disabilities report in the provider's beneficiary's
				file.
v. Contact lenses will be
				provided once every two years for persons age 19 through and including 59 years
				of age, and once a year for persons up to age 19 or 60 years of age and older.
(1) Replacement of a contact lens in less
				than the timeframes in this subparagraph is allowed only if there is a need for
				a change in the fit or design of the lens or if there has been a prescription
				change of 0.50 diopter in spherical or astigmatic power. The need for a
				replacement due to a change in the fit or design of the lens shall be
				determined by the vision care professional based on an examination of the
				patient.
8.
				Dual pairs of glasses instead of multifocal;
9. Contact lenses;
10. Polycarbonated or ultraviolet filter
				lenses, when recommended by the prescribing practitioner as medically
				necessary;
11. Intraocular lenses;
				and
12. Protective prescription
				eyewear that is needed by a specific child beneficiary because it is required
				pursuant to
				N.J.S.A.
				5:18-1 while the child participates in
				sports.