SUBCHAPTER 63G - MEDICAL/EYE CARE PROGRAM

section .0100 – services

10A ncac 63G .0101 COVERED SERVICES

(a) Services provided to any eligible North Carolina resident, pursuant to G.S. 111-8, include:

(1) eye examinations. Refractions are restricted to one every two years for persons 25 years of age or older and one refraction per year for persons under 25 years of age, without prior approval by division staff;

(2) treatment to the eye including medication;

(3) eyeglasses and ocular prostheses. Eyeglasses are restricted to one pair every two years for persons 25 years of age or older and one pair per year for persons under 25 years of age, without prior approval by Division staff. Contact lenses are restricted to therapeutic types;

(4) hospitalization for eye‑related disorders; and

(5) surgery to the eye and supporting structures except that there shall be no cosmetic surgery for adults and no payment shall be made for unnecessary surgery as determined by the State Supervising Ophthalmologist. The State Supervising Ophthalmologist is a medical doctor with a specialty in ophthalmology duly licensed to practice by the State of North Carolina. Services are obtained by contract between the Agency and practitioner.

(b) Prior Approval:

(1) A second refraction request within the time limitation period must be submitted on the general Request for Prior Approval form documenting the medical necessity for a second refraction (loss of vision, significant decrease in acuity, eye injury, retinal or muscle surgery, etc.).

(2) Prior approval is required for all visual aids. The Area Nursing Eye Care Consultant reviews each request for prior services, medical justification, necessity, age, and other criteria before approving or denying the request.

(3) Prior approval is required for all treatment, surgery, and prescription drugs. The Area Nursing Eye Care Consultant reviews each request for prior services, medical justification, necessity, age, and other criteria before approving or denying the request.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; September 1, 1984; February 1, 1983; July 1, 1981;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0102 ELIGIBILITY CRITERIA

(a) A North Carolina resident is eligible to receive services if:

(1) the services are not covered by the North Carolina medical assistance (medicaid) program; or

(2) the resident is a medicaid recipient on a spend‑down who qualifies under the appropriate income criterion; or

(3) the services cannot be reimbursed by any other state or federal program providing eye care.

(b) If the resident is a preschool child or school age child, the family's annual net income cannot exceed the amounts as established by the General Assembly.

(c) If the resident is an adult, the family's annual net income cannot exceed the amount set out in the North Carolina Budget Bill.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; April 1, 1990; July 1, 1987; February 1, 1986; December 1, 1983;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0103 APPLICATION FOR SERVICES

(a) In order to be determined eligible for services, pursuant to this Subchapter, the resident must:

(1) have been determined to be ineligible for medicaid and other state or federal programs that offer eye care services or eligible for Medicaid but required to meet a spend-down before Medicaid coverage becomes effective;

(2) complete the application for services in person or by mail; and

(3) verify income in the form of a statement from their employer or written proof of other sources of income.

(b) Individuals wishing to apply for services may contact either the county department of social services or the Division of Services for the Blind field office to determine where application should be made.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. August 1, 1977; January 1, 1977; February 19, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; April 1, 1990; December 1, 1983; July 1, 1981; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0104 ELIGIBILITY FOR SERVICES

(a) The Division may, based upon the availability of funds, issue any resident determined eligible for services an authorization for an eye examination and a certification for fitting and dispensing of eyeglasses. These copies must be taken by the applicant to his selected vendor and will authorize the Division of Services for the Blind to pay only for eye examinations by physicians (ophthalmologists) or optometrists and fitting and dispensing of eyeglasses. If the Division determines that sufficient funds are not available to provide all services, the Division may elect to fund surgery, treatment, and medication first.

(b) All other services including purchase of eyeglasses, medications, follow-up visits, surgery, and other treatments must receive prior approval from the Division of Services for the Blind.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. August 1, 1977; January 1, 1977; February 19, 1976.

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; July 1, 1981; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0105 RETROACTIVE ELIGIBILITY

The division may issue authorizations to pay for emergency inpatient and outpatient surgery and hospital services plus other services or treatment provided prior to determining eligibility if:

(1) services were received no more than 90 days before application;

(2) the person would have been eligible at the time the services were performed; and

(3) the services were those covered by this program.

Surgery and hospitalization not of an emergency nature requires prior approval.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; July 1, 1987; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A NCAC 63G .0106 REDETERMINATION

A redetermination of eligibility is mandatory every six months because of possible changes in economic circumstances.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. January 1, 1990; February 1, 1986; June 1, 1982; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

section .0200 – administrative procedures

10A ncac 63G .0201 USE OF authorization and certification

(a) The consumer shall deliver the authorization to the eye practitioner for the examination and the certification for fitting and dispensing to the eye practitioner or licensed optical provider who will provide these services.

(b) Out‑of‑state services must have prior approval by the state supervising ophthalmologist.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. August 1, 1977; January 1, 1977; November 8, 1976; February 19, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0202 CLAIMS

(a) Claims for services or supplies must be submitted no later than twelve months from the date of service. The division shall not pay claims received more than 12 months from the date of service.

(b) The amount reimbursed is payment in full. The consumer shall not be billed for any unrealized balance except a co‑payment. A co‑payment not to exceed five dollars ($5.00) may be charged the consumer by both the practitioner who provides the eye exam and follow-up and by the optical supplier. This will reduce the division's liability by the amount of the co‑payment.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. November 8, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; February 1, 1986; June 1, 1983; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0203 FRAUD: PAYMENT OF CLAIM

(a) All services billed by licensed eye practitioners and optical providers, institutions and suppliers must be consistent with the services actually performed.

(b) The Division shall use the Medicaid schedule of benefit payments for services charged the Division. This schedule is maintained by the Department of Health and Human Services. Division of Medical Assistance, 1985 Umstead Drive, Raleigh, NC 27603‑2001. The schedule is incorporated by reference including subsequent amendments and additions.

(c) Licensed eye practitioners, licensed optical providers, institutions, and suppliers must keep records disclosing the services charged the division for five years. The division may have access to these records on written request by the division director.

History Note: Authority G.S. 108‑48; 111‑8; 111‑23; 143B‑157;

Eff. February 1, 1976;

Amended Eff. July 1, 1976; February 19, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; April 1, 1990; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0204 FREEDOM OF CHOICE

In accordance with G.S. 90‑127.1, all eligible consumers shall be afforded a free choice to select a licensed eye practitioner or optical provider to receive services.

History Note: Authority G.S. 90‑127.1; 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. February 19, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0205 EXAMINATION REPORTS

(a) An eye examination report shall be completed by ophthalmologists and optometrists on all persons having:

(1) a chronic, degenerative eye disorder; or

(2) no vision or vision with glasses so defective as to prevent the performance of ordinary activities requiring sight.

(b) The Division may request specific reports on persons not meeting the criteria in Paragraph (a) of this Rule, with the person's consent.

History Note: Authority G.S. 111-4; 111‑8; 143B‑157;

Eff. February 1, 1976;

Amended Eff. February 19, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; April 1, 1990; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

SECTION .0300 - HEARING

10A ncac 63G .0301 appeal of division actions

(a) If a consumer is dissatisfied with an action or service delivered by the medical/eye care program, that consumer may request a conference with the program chief for the Medical/Eye Care Program.

(b) A conference shall be held within 15 working days from the receipt of the original request.

(c) If the conference solves the grievance or dissatisfaction, this shall be stated in writing by the program chief and signed by the Consumer.

History Note: Authority G.S. 111‑8; 143B‑157;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.

10A ncac 63G .0302 request FOR contested case HEARING

(a) If the results of the conference are unsatisfactory, the consumer shall be informed by the Division of his or her right to a contested case hearing.

(b) All contested case hearings shall be heard by the Office of Administrative Hearings pursuant to G.S. 150B, Article 3. The consumer shall be notified by the designated agency representative in writing that he has the right to petition the Office of Administrative Hearings and request a contested case hearing. The consumer shall be instructed by the designated agency representative to contact OAH and request the specific forms to be completed.

(c) In this same written notice the consumer shall be instructed that they have 60 calendar days from the date they receive the agency notice to request a contested case hearing through OAH. Any petition for a contested case must be returned by the consumer directly to the Office of Administrative Hearings.

History Note: Authority G.S. 111‑8; 143B‑157; 150B‑23;

Eff. February 1, 1976;

Readopted Eff. November 16, 1977;

Amended Eff. August 1, 2002; December 1, 1990; April 1, 1990; June 1, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 23, 2015.