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Eyeglass Replacements/Repairs for Members Covered by EPSDT
Applicable To: Mercy Care Complete, Mercy Care RBHA, Mercy Care DD, Mercy Care Long Term Care and Mercy Care DCS CHP
On March 17, 2022, Mercy Care sent a Provider Notification regarding Eyeglass Coverage. Please click on the link to review the notification in further detail.
AHCCCS has released further information regarding this topic that we would like to share with you.
As a reminder, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program provides comprehensive health care services through primary prevention, early intervention, diagnosis, and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for persons under the age of 21 years. As part of EPSDT, eyeglasses and other vision services, including replacement and repair of eyeglasses, for members under the age of 21 years are covered by AHCCCS to correct or ameliorate conditions discovered during vision screenings for EPSDT. There are no restrictions for EPSDT members for replacement and repair of eyeglasses, when medically necessary for vision correction. This includes, but is not limited to, loss, breakage, or change in refraction. To receive eyeglass replacement or repair, EPSDT members do not need to wait for their next scheduled EPSDT well child visit.
For members under the age of 21, federal law requires AHCCCS to cover all services listed in 42 USC 1396d(a) when medically necessary and cost effective, even when the services are not listed as covered services in the AHCCCS State Plan, AHCCCS statutes, rules, or policies. This means that health plans shall cover these services for EPSDT members if the treatment or service is necessary to “correct or ameliorate” defects or physical and behavioral illnesses or conditions, as long as the services are not experimental.
In addition, providers and dispensers are to be cautioned about “upselling” equipment for members. Members are not required to agree to any upgrades. To the extent that any upgrade is not AHCCCS covered and is to be a member responsibility, the provider must ensure the member agrees to accept financial responsibility and signs a document, in advance, accepting payment responsibility. The member agreement of financial responsibility document must also provide a description and approximate cost. General requirements for member billing are discussed in AAC R9-22-701.
Vision providers and dispensers are required to post information regarding eyeglass related coverage requirements for EPSDT members on their websites (including, but not limited to, unlimited eyeglass replacement and repair when medically necessary). In addition, vision providers and vendors should not promote the purchase of insurance or warranty plans to members, given the extensive coverage for eyeglass repair and replacement.
AHCCCS systems have been reviewed to ensure eyeglass coverage is consistent with the provisions outlined in this notification.
Mercy Care is committed to ensuring the availability of timely, quality healthcare. If a caregiver is unable to access health services for the child/youth in their care, or if they have a concern about the quality of care, please support them in calling Mercy Care Member Services at 602-212-4983 or 1-833-711-0776 (TTY/TDD: 711). If their concern is not resolved, please support them in calling the AHCCCS Clinical Resolution Unit at 602-364-4558, or 1-800-867-5308.
Please contact your Mercy Care Network Management representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.
We appreciate your continued assistance, support and cooperation!
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