What are the rules that apply to SoonerCare in Oklahoma? Well a lot of these rules are based upon age, there are different sets of rules regarding children, adults and pregnant females.
Children’s vision and eye health exams:
Eye examinations are covered when medically necessary. Determination of the refractive state is covered when medically necessary. Basically the state acknowledges the need and importance for children to see well and have healthy eyes, so their exams are covered as is their needed eye wear or treatment of ocular disease, infections and allergies.
(a) children lenses, frames, low vision aids Coverage includes one set of lenses and frames per year.
(b) Corrective lenses must be based on medical need. Medical need includes a change in prescription or replacement due to normal lens wear.
(c) SoonerCare provides frames 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.
(d) Replacement of or additional lenses and frames are allowed when medically necessary. Prior authorization is not required; however, the provider must document in the patient record the reason for the replacement or additional eyeglasses. The OHCA or its designated agent will conduct ongoing monitoring of replacement frequencies to ensure guidelines are followed. Payment adjustments will be made on claims not meeting these requirements.
(f) Bifocal lenses for the treatment of accommodative esotropia are a covered benefit. Polycarbonate lenses are covered for children when medically necessary.
(g) Replacement of lenses and frames due to abuse and neglect by the member is not covered.
Adult’s vision and eye health exams:
Adults are covered for medically necessary examinations (due to an injury, infection or disease). Vision examinations are not covered nor are the visual aids to correct the refractive state of the eyes. Payment is made only for treatment of medical or surgical conditions which affect the eyes. Prior to providing non-covered services, providers must notify members in writing of those services not covered by SoonerCare. Determination of refractive state or other non-covered services may be billed to the patient if properly notified. Individuals eligible for Part B of Medicare. Payment is made utilizing the Medicaid allowable for comparable services.
BA Eye Site is a SoonerCare Eye Doctor, we are proud to be a SoonerCare Optometrist. There is a lot of joy being able to impact the future of children in Oklahoma. Vision is critical to learning in school and sports which helps shape better citizens and leaders of tomorrow. Call and see our qualified team today. We have opening for Back to School.