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STATE OF OKLAHOMA
2nd Session of the 59th Legislature (2024)
HOUSE BILL 3882 By: Ford
AS INTRODUCED
An Act relating to Medicaid; providing for Medicaid
coverage for eye exams and eyeglasses for adults;
providing for codification; and providing an
effective date.
BE IT ENACTED BY THE PEOPLE OF T HE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 4005 of Title 56, unless there
is created a duplication in numbering, reads as follows:
Payment for adult members is made to optometrists through
SoonerCare as set forth in this section.
A. Eye examinations are covered when medically necessary.
Determination of the refractive state is covered when medi cally
necessary.
B. Payment can be made for medical services that are reasonabl e
and necessary for the diagnosis and treatment of illness or injury
up to the patient's maximum number of allowed office visits per
month.
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1. Payment is made for tr eatment of medical or surgical
conditions which affect the eyes ;
2. The global surgery fee allowance includes preoperative
evaluation and management services rendered the day before or the
day of surgery, the surgical procedure, and routine postoperative
period. Co-management for cataract surgery is filed using
appropriate CPT codes, modifier s, and guidelines. If an optometrist
has agreed to provide postoperative care, the surgeon 's information
must be in the referring provider 's section of the claim ; and
3. Payment for laser surgery to optometrist is limited to those
optometrists certified b y the Board of Optometry as eligible to
perform laser surgery ; and
C. When medically necessary, payment will be made for lenses,
frames, low vision aids, and certain tints for adults. Coverage
includes lenses and frames to protect adults with monocular vision.
Coverage includes two sets of non -high-index polycarbonate lenses
and frames per year. Any lenses and frames beyond this limit must
be prior authorized and determined t o be medically necessary. All
non-high-index lenses must be polycarbonate .
D. Corrective lenses must be based on medical need. Medical
need includes a significant change in prescription or replacement
due to normal lens wear .
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E. SoonerCare provides fram es when medically necessary. Frames
are expected to last at least one year and must be reusable. If a
lens prescription changes, the same frame must be used if possible .
F. Providers must accept SoonerCare reimbursement as payment in
full for services rendered, except when authorized by SoonerCare ,
including but not limited to , copayments or other cost sharing
arrangements authorized by the state:
1. Providers must be able to dispense standard lenses and
frames which SoonerCare would fully reimburse wit h no cost to the
eligible member; and
2. If the member wishes to select lenses and frames with
special features which exceed the SoonerCare allowable fee, and are
not medically necessary, the member may be billed the excess cost.
The provider must obtain signed consent from the member
acknowledging that they are selecting lenses an d/or frames that will
not be covered in full by SoonerCare and that they will be
responsible to pay the excess cost. The signed consent must be
included in the member 's medical record;
G. Replacement of or additional lenses and frames are allowed
when medically necessary. The Oklahoma Health Care Authority does
not cover lenses or frames meant as a backup for the initial
lenses/frames. Prior authorization is not req uired unless the
number of glasses exceeds two per year. The provider must always
document in the member's record the reason for the replacement or
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additional lenses and frames. The OHCA or its designated agent will
conduct ongoing monitoring of replacement frequencies to ensure OHCA
policy is followed. Payment adjustments will be made on c laims not
meeting these requirements ;
H. A fitting fee will be paid if there is documentation in the
record that the provider or technician took measurements of the
member's anatomical facial characteristics, recorded lab
specifications and made final adj ustment of the spectacles to the
visual axes and anato mical topography. A fitting fee can only be
paid in conjunction with a pair of covered lenses and frames .
I. Bifocal lenses for the treatment of accommodative esotropia
are a covered benefit. Progressive lenses, trifocals, photochromic
lenses, and tints for adults require prior authorization and must
satisfy the medical necessity standard. Payment is limited to two
glasses per year. Any glasses beyond this limit must be prior
authorized and determin ed to be medically necessary.
J. Replacement of lenses and frames due to abuse and neglect by
the member is not covered .
K. Bandage contact lenses are a covered benefit for ad ults.
Contact lenses for medically necessary treatment of conditions such
as aphakia, keratoconus, following keratoplasty,
aniseikonia/anisometropia or albinism are a covered benefit for
adults. Other contact lenses for children require prior
authorization and must satisfy the medical necessity standard.
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SECTION 2. This act shall become effective November 1, 2024.
59-2-9681 TJ 01/10/24