Section 140.417  Limitations on Optometric Services

Payment for the following optometric services and materials shall be made subject to the following limitations:

a)         Payment shall be made for single vision lenses only when the following conditions are met:

1)         The power is at least 0.75 diopters in either the sphere or cylinder component; or

2)         The difference between the old and new prescription is at least 0.75 diopters in either the sphere or cylinder component.

b)         Payment shall be made for bifocal lenses only when the following conditions are met:

1)         For first bifocals, the power of the bifocal addition is at least 1.00 diopter.

2)         For a change in bifocal lenses, the power of the bifocal addition is changed by at least 0.50 diopters or the distance power represents a change of at least 0.75 diopters.

c)         Payment shall be made for more than one examination per year only when the vendor documents the need for the additional examination.

d)         Effective July 1, 2012, payment shall be made for the following:

1)         One pair of eyeglasses or set of lenses for adults in a 24-month period.  Effective August 18, 2017, adults 21 years of age and older may receive an additional pair of eyeglasses or set of lenses within the 24-month period if the patient has had a surgical procedure that necessitates a new pair.

2)         Payment shall be made for more than one pair of eyeglasses or set of lenses per year for children through age 20 only when the physician or optometrist documents:

A)        that:

i)          the most recent pair of eyeglasses or set of lenses was lost or destroyed for reasons beyond the control of the recipient; or

ii)         there is a change in the prescription that meets the requirements in subsection (a)(2) or (b)(2); and

B)        that the additional pair is medically necessary.

e)         Payment for optometric materials dispensed by a supplier other than a physician or optometrist, except for replacement and repair items, shall be made only when they are prescribed by a licensed physician or optometrist.

f)         Effective July 1, 2012, prior approval pursuant to Section 140.40 is required for the services and materials described in this subsection (f).  Approval shall be given when, in the judgment of a Department consultant, the requested item or service is appropriate.

1)         Contact lenses and related contact lens services;

2)         Custom made artificial eyes;

3)         Low vision devices;

4)         Any item or service not specifically included in the schedule of procedures for optical services and supplies; and

5)         An additional pair of eyeglasses or set of lenses within a 24-month period for adults 21 years of age and older after eye surgery.

(Source:  Amended at 42 Ill. Reg. 20059, effective October 26, 2018)