ELIMINATION OF MEDI-CAL
OPTOMETRY/OPTICAL BENEFITS
FREQUENTLY ASKED QUESTIONS
QUESTION:
Why are optometry/optical benefits being eliminated?
ANSWER: In
an effort to balance CA State Budget, the California Legislature, during the
Third Extraordinary 2009-2010 Legislative Session, ratified Assembly Bill (AB)
X3 5 (Evans, Chapter 20, Statutes of 2009), the budget trailer bill. AB X3 5 contained provisions to eliminate
certain Medi-Cal optional benefits, effective July 1, 2009. In addition, the Legislature also enacted law
requiring the Treasurer and Director of Finance to determine whether additional
federal funding of not less than $10 billion would be available by June 30,
2010 to offset general fund expenditures and to reverse the optional benefit
elimination.
In March, State Treasurer
Bill Lockyer and Director of Finance Mike Genest jointly determined that $10
billion of additional federal funding would not be available by June 30, 2010
to offset general fund expenditures. Therefore, effective July 1, 2009, the
following Medi-Cal optional benefits will be eliminated for adult recipients
ages 21 years and older:
·
Acupuncture
services
·
Adult dental
services
·
Chiropractic
services
·
Incontinence
creams and washes
·
Optician/optical
laboratory services
·
Optometry services
·
Podiatry
services
·
Psychology
services
·
Speech therapy
and audiology services
QUESTION: What is an “optional” benefit?
ANSWER: Federal
law requires the Medi-Cal program to provide a core of basic services,
including but not limited to hospital inpatient and outpatient care, skilled
nursing care, physician visits, laboratory tests and X-rays, family planning,
regular examinations for children under 21 years and services in rural health
clinics. All other services are considered “optional” benefits because they are
provided at the “option” of each state.
QUESTION:
Is the elimination of optional benefits temporary? If not, when will these services be available
again?
ANSWER:
Since the law does not specify a date when these optional benefits would be
reinstated, the elimination is indefinite.
The Legislature and the Administration would have to approve any changes
to the current law. Providers should
continue to check the Department of Health Care Services (www.dhcs.ca.gov) and Medi-Cal (www.medi-cal.ca.gov) Web sites for
notices and articles for any updates.
QUESTION: Does
the elimination of optional benefits impact only Medi-Cal recipients 21 years
of age and older? Which recipients are
excluded?
ANSWER: Yes,
the elimination of optional benefits affects only Medi-Cal recipients 21 years
of age and older. These optional benefits will continue to be available for
Medi-Cal recipients under 21 years of age with full-scope benefits, recipients
receiving the service(s) due to a condition that might complicate a pregnancy,
and those residing in skilled and intermediate care nursing facilities as defined in
Health and Safety Code (H&S), Section 1250 (c) and (d) and licensed in
accordance to H&S Section (k).
QUESTION: Does the elimination of optional
benefits impact both Medi-Cal fee-for-service and Managed Care plans?
ANSWER: Yes.
QUESTION:
Which programs are not affected by these optional benefit eliminations?
ANSWER:
The following programs are not impacted?
·
Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) Program
·
California
Children’s Services (CCS) Program
·
Genetically Handicapped Persons Program (GHPP)
·
County Mental
Health Services
·
Home Health Agency
(HHA) services
·
Adult Day Health
Care Centers (ADHCs) services
·
Healthy Families
Program
·
QUESTION:
Is the elimination of optometry services for routine eye examinations and
eyeglasses only? Can I still see a
patient for primary eye care services to treat an eye infection or other
medically related conditions?
ANSWER: All
services provided by optometrists for Medi-Cal recipients 21 years of age and
older minus those excluded recipients mentioned above are eliminated.
QUESTION:
Can an adult Medi-Cal recipient be examined by an ophthalmologist?
ANSWER:
Yes. Physician services are exempt from
the elimination of optional benefits.
QUESTION:
Can an adult Medi-Cal recipient receive eyeglasses from an ophthalmologist?
ANSWER:
No. All eye appliances including
eyeglasses, contact lenses, and low vision aids will no longer be covered for
Medi-Cal recipients 21 years of age and older minus those excluded recipients
mentioned above effective July 1, 2009.
QUESTION:
If the service was performed prior to July 1, 2009, can I still bill for an
eliminated service after this date?
ANSWER:
Yes, claims with dates of service prior to July 1, 2009 can be billed after
this date and follow the same timeliness requirements.
QUESTION:
Can we still see Medi-Cal/Medicare recipients after July 1, 2009? If yes, how do we bill Medi-Cal for these
patients?
ANSWER:
Yes, you can still examine patients who have Medicare/Medi-Cal dual eligibility
after July 1, 2009. When billing after July 1, 2009, follow the guidelines
below:
QUESTION:
What happens when the Medi-Cal eligible beneficiary reaches 21 years of age
during the course of treatment but after the July 1, 2009 implementation date?
ANSWER: Recipients
that are under 21 years of age and whose plan of care and course of treatment
is scheduled to continue after he/she turns 21 yrs of age can continue services
until the end of their course, even if it is after July 1, 2009 implementation
date
QUESTION:
What happens if a Medi-Cal eligible beneficiary 21 years of age and older
requires additional time to complete treatment for a course of treatment that
began prior to service date July 1, 2009?
ANSWER: Recipients
that are 21 years of age and older and whose plan of care and course of
treatment for an acute ocular condition began prior to July 1, 2009 can
continue services until the end of their course, even if it is after July 1,
2009 implementation date.
QUESTION:
How do I bill claims for patients who require continuing care?
ANSWER:
All continuing care services must be billed with Modifier –GY. Those services that require a Treatment
Authorization Request (TAR) will continue to require a TAR after July 1, 2009. Non-TAR services must be billed with Modifier
–GY with medical justification included in the medical record.
QUESTION:
Would services that are provided to an exempt beneficiary require medical
documentation and/or justification with claim submission?
ANSWER:
Providers should always include medical justification for the service in the medical
record. Instructions for billing will
released through bulletin on the Medi-Cal web site (www.medi-cal.ca.gov) prior to the July
1, 2009 implementation date.
QUESTION:
How does the elimination of optional benefits impact how orders are processed
on the Prison Industry Authority (PIA) Optical Online Web Site?
ANSWER:
Please refer to a separate FAQ posted on the PIA Optical Online Web Site
addressing the processing of optical orders, which can be accessed at https://optical.pia.ca.gov/POOL/FAQ_Links.htm
If you have any questions,
please contact Dr. Cory Vu at the address below:
Vision Services Branch
Attn: Cory N. Vu, O.D.
Phone: (916) 552-9539
E-mail: cory.vu@dhcs.ca.gov