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.