No. 32106: R414-52. Optometry Services

DAR File No.: 32106
Filed: 10/30/2008, 03:00
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with budget reduction mandates set forth in the 2008 Second Special Session of the Utah Legislature.

Summary of the rule or change:

This change allows only pregnant women and individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) to receive eyeglasses under this rule. It further removes the $3 copayment for eyeglasses that the Department currently applies to recipients who fall under the copayment requirement.

State statutory or constitutional authorization for this rule:

Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department estimates an annual savings of $231,252 to the General Fund and $558,275 in federal dollars as a result of this change. These estimates also apply to the companion filing to this proposed rule (Rule R414-53). (DAR NOTE: The proposed 120-day (emergency) rule for R414-53 is under DAR No. 32107 in this issue, November 15, 2008, of the Bulletin.)

local governments:

This change does not impact local governments because they do not fund or provide optometry services to Medicaid clients.

small businesses and persons other than businesses:

Providers of eyeglasses services will lose approximately $789,528 in annual revenue as a result of this change. However, the total out-of-pocket expense to Medicaid clients who elect to pay out-of-pocket to receive eyeglasses is difficult to estimate because it is impossible to know how many clients would choose this option. Further, there are a wide range of options and prices available for eyeglasses. The above estimate and explanation also apply to Rule R414-53, which is a companion filing to this proposed rule.

Compliance costs for affected persons:

The annual loss in revenue to a single provider of eyeglasses is approximately $43,863 based on the total number of providers and client visits per year. However, the annual out-of-pocket expense to a single Medicaid client who elects to pay out-of-pocket to receive eyeglasses is difficult to estimate because it is impossible to know how many clients would choose this option. Further, there are a wide range of options and prices available for eyeglasses. The above estimate and explanation also apply to Rule R414-53, which is a companion filing to this proposed rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change reflects the reductions passed in S.B. 2001 (2008 2nd Spec Sess) and are necessary to file under emergency authority to immediately implement the budget reductions. David N. Sundwall, MD, Executive Director (DAR NOTE: S.B. 2001 (2008 2nd Spec Sess) is found at Chapter 9, Laws of Utah 2008, and was effective 10/15/2008.)

Emergency rule reason and justification:

Regular rulemaking procedures would cause an imminent budget reduction because of budget restraints or federal requirements.

This change is necessary to comply with budget reduction mandates set forth in the 2008 Second Special Session of the Utah Legislature.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

This rule is effective on:

11/01/2008

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-52. Optometry Services.

R414-52-3. Client Eligibility Requirements.

Optometry services are available to categorically and medically needy individuals, except that the provision of eyeglasses is only available to pregnant women and individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).

 

R414-52-5. Reimbursement.

(1) Fees for services for which the Department will pay optometrists are established from the physician's fees for CPT codes as described in the State Plan, Attachment 4.19-B, Section D Physicians. [A $3 copayment for each pair of eyeglasses is applied to Medicaid recipients who fall under the copayment requirement. ]Fee schedules were initially established after consultation with provider representatives. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.

(2) The Department pays the lower of the amount billed and the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.

 

KEY: Medicaid, optometry

Date of Enactment or Last Substantive Amendment: November 1, 2008

Notice of Continuation: May 19, 2008

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3