Frequently Asked Questions

Elimination of Eyeglass Benefits

 

Question: Why were eyeglasses eliminated for adult Medi-Cal recipients?

 

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. 

 

Question: Which other optional benefits were eliminated?

 

Answer: The following optional benefits were eliminated for Medi-Cal recipients 21 years of age and older pursuant to AB X3 5, effective July 1, 2009:

 

  • Adult dental services
  • Acupuncture services
  • Audiology services and speech therapy services
  • Chiropractic services
  • Optician services, including services provided by a fabricating optical laboratory
  • Podiatric services
  • Psychology services
  • Incontinence creams and washes

 

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 were not affected by these optional benefit eliminations?

 

Answer: The following programs were 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
  • County Medical Services Program

 

 

Question: Can an optometrist still see a patient for a comprehensive eye examination and primary eye care services to treat an eye infection or other medically related conditions?

 

Answer: All diagnostic, ancillary, and supplemental ophthalmological services provided by optometrists for Medi-Cal recipients will remain Medi-Cal benefits. However, services for the dispensing or repair of eyeglasses and other eye appliances are no longer covered under the Medi-Cal program.

 

Question: If eyeglasses were ordered for a patient prior to reaching his/her 21st birthday, but dispensed to the patient after this date, will I still be reimbursed?

 

Answer: Yes, as long as the date of service billed on the claim is prior to the patient's date of birth.

 

Question: How do I submit orders on the CALPIA Optical Online Web site for Medi-Cal recipients on or after July 1st, 2009 and does it require prior authorization?

 

Answer: For Medi-Cal patients under 21 years of age, orders will process as usual on the CALPIA Optical Online (POOL) Web site. For those patients ages 21 and over, POOL will require that you certify online that the patient currently resides in a skilled nursing or intermediate care facility or is receiving continuing care for services provided prior to July 1st, 2009. Once you certify that the patient meets the above conditions, the order will process as usual and no prior authorization is required.

 

Question: How do we process an order for a patient in a skilled nursing or intermediate care facility?

 

Answer: POOL will require that you enter the name and National Provider Identifier (NPI) of the nursing facility where the patient resides before the order can be entered.

 

Question: How do we process a redo through POOL after July 1, 2009?

 

Answer: POOL will allow a doctor or lab redo to be processed within 90 days of the ship date of the original order. The online redo process remains the same.

 

Question: My patient’s eyeglasses were lost/broken/stolen. Can I replace them?

 

Answer: Only the following persons can have their eyeglasses replaced after July 1, 2009:

 

a.     Women who are pregnant and only if medical justification indicate that not replacing the eyeglasses may cause a problem to the pregnancy.

b.     Children or young adults who are 20 years old and younger and are full scope Medi-Cal.

c.     People who reside in a skilled nursing facility, intermediate care facility (ICF), ICF-Nursing, or ICF-Habilitative.

 

Question: Which CALPIA optical lab will continue to process orders for eligible Medi-Cal beneficiaries?

 

Answer: Only Valley State Prison for Women and California State Prison at Solano are accepting optical orders for eligible Medi-Cal beneficiaries.