COA Medicaid Reminders
The COA continues to get questions about the billing of aspheric lenses to Medicaid. Below you will find useful links and pertinent information that should help clarify proper billing practices. This is informational only; nothing in this text should be considered legal advice. Please reach out to the COA office if you do not find the answers you are looking for within this text.
GENERAL INFORMATION
Code of Colorado Regulations 10 CCR 2505-10 8.200 (Vision Services pages 50-55)
CO Medicaid Vision Benefit Billing Manual
CO HCPF Provider Bulletins (updates to benefits and billing practices are published here)
HISTORY
October 2024:
While CO Department of Health Care Policy and Finance clarified in a bulletin that it would not pay for both a spherical code and an aspherical code (Issue 103), CMS has clearly defined which are base codes and which are add on codes.
CMS Refractive Lenses Coding Guidelines - Policy Article
Codes V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2399, V2410, V2430, V2499, V2700, and V2770 describe specific eyeglass lenses. Only one of these codes may be billed for each lens provided. These codes include both aspheric and nonaspheric lenses.
Codes V2115, V2118, V2121, V2215, V2218, V2219, V2220, V2221, V2315, V2318, V2319, V2320, V2321, V2710, V2715, V2718, V2730, V2744, V2745, V2750, V2755, V2756, V2760, and V2780, V2781, V2782, V2783, V2784, V2786, V2797 describe add-on features of lenses. They are billed in addition to codes for the basic lens.
April 11, 2025:
After an expedited stakeholder process due to suspicion of fraud because of the “magnitude and frequency” of aspheric lens prescriptions, the new Rule took effect. HCPF reported that the national average for medically necessary aspheric lenses is 6% and that utilization in Colorado far exceeded that. The Rule change removed the prohibition of prior authorization (though a PAR is not currently required) and set parameters for which aspheric lenses could be prescribed. They will now only be covered when the spherical equivalent power is equal to or greater than +/- 6.0 D (use for other Rx parameters would require PAR approval).
THE BENEFIT
The Colorado Medicaid Billing manual for Eyeglass and Vision services and the Colorado Code of Regulations 8.203.4.B. Eyeglasses Rule define coverage for clients 20 Years of Age or Younger as follows:
- Frames and lenses are covered for a client 20 years of age or younger if:
i) Medically necessary, as defined in section 8.076.1.8;
ii) Prescribed by a provider who meets the criteria at 8.203.3.A.; and
iii) Purchased through a provider who meets the criteria at 8.203.3.B.
- Per prescription, covered frames and lenses for a client 20 years of age or younger are limited to:
i) One (1) eyeglasses frame; and
ii) Up to two (2) lenses that are:
1) Single or multi-focal; and
2) Clear glass, plastic, or polycarbonate.
Considering the above benefit, further definitions and clarifications would be as follows:
A. DEFINITION OF MEDICAL NECESSITY According to 10 CCR 2505-10 section 8.076.1.8, a service is considered medically necessary when it:
a) Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all. For members under age 21, per section 8.280.4E, this includes a reasonable expectation that the service will assist the member to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living.
b) Is provided in accordance with generally accepted professional standards for health care in the United States.
c) Is clinically appropriate in terms of type, frequency, extent, site, and duration.
d) Is not primarily for the economic benefit of the provider or primarily for the convenience of the member, caretaker, or provider.
e) Is delivered in the most appropriate setting(s) required by the member's condition.
f) Is not experimental or investigational; and
g) Is not more costly than other equally effective treatment options.
There is no “annual benefit” for glasses. Glasses are only covered when medically necessary.
Other pertinent information to consider:
The Vision Benefit states that:
- Repair of eyeglasses is covered only when due to broken frames or lenses.
- Replacement glasses shall be provided when medically necessary or when the glasses are damaged to the extent that repairs are not cost effective.
“Replacement glasses” would not include second or third pairs of glasses.
WHAT TO DO
CO Medicaid has defined Provider Self-Disclosure and overpayment regulations. If you believe you are in violation, you should consider consulting an attorney and/or following the overpayment guidelines. Given that all healthcare practices should have a compliance plan, which should include self-audits of medical records, finding overpayment issues would be found in a self-audit. Self-disclosure is not an admission of fraud or abuse.
