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Insured Optometric Services Tariff Regulations

made under Section 13 and subsection 17(2) of the

Health Services and Insurance Act

R.S.N.S. 1989, c. 197

O.I.C. 2013-290 (August 20, 2013), N.S. Reg. 288/2013



Citation

1     These regulations may be cited as the Insured Optometric Services Tariff Regulations.


Insured optometric services

2     The insured optometric services are as set out in the following table:


Health Service

Code

Description

Conditions for Coverage

Insured

Ages

Frequency

Medical

Service

Units

09.02C

Full exam–routine

 

0-9 yrs, 65 yrs & over

1 per 2-yr period

20.48

09.02C

Full exam–routine

(physician referral only)

 

0-9 yrs, 65 yrs & over

1 per 2-yr period

24

09.02C

Full exam–non-routine

  medical necessity

any age

1 per yr

20.48

09.02C

Full exam–non-routine

(physician referral only)

  medical necessity

any age

1 per yr

24

09.02F

Full exam–optometric vision analysis under enhanced vision screening program

 

up to 19 yrs

no limitation

20.48

09.02G

Low vision assessment

  patient must have subnormal vision, and not able to perform normal activities with spectacles

  acuity must be at least 20/50 or worse in the better eye

any age

1 per 2-yr period, for initial assessment


1 follow-up to ensure devices being used correctly and address any other needs

30, for initial assessment


13, for subsequent assessment

3.03

Continuing care

  medical necessity

any age

1 per yr

11

3.03

Continuing care (physician referral only)

  medical necessity

any age

1 per yr

11

3.03

Continuing care

(other than physician referral)

  medical necessity

any age

1 per yr

11

3.03

Continuing care in conjunction with attending & describing differential diagnosis

  eye pathology is identified or suspected

  a specific diagnostic code is indicated (in acc. with MSI Optometry Manual)

  must be submitted with text indicating the drug prescribed or that no prescription required

  optometrist must hold valid optometric drug licence

any age

6 per yr

11

3.03

Continuing care in conjunction with attending & describing differential diagnosis, when diagnosis warrants referral to ophthalmologist

  visit must result in referral to ophthalmologist

  must be submitted with text indicating the name of the ophthalmologist receiving the referral

a[n]y age

1 per patient incident

14

3.03

Diagnostic interview and evaluation described as limited ophthalmologist referral

  oph[th]almologist refers patient back to optometrist for follow-up care

any age

2 per year

11, for continuing care


14, for continuing care in conjunction with attending and describing differential diagnosis

22.69A

Punctal occlusion

  eye pathology is identified or suspected

  permanent plugs only

  insertions only, not materials

  not for contact lense[lens]-related dry eye

any age

1 per eye per lifetime

22, for unilateral


33, for bilateral

21.31

Dilation of lacrimal punctum

  eye pathology is identified or suspected

  true epiphora

  positive Jones test

  patient must not have ectropion

any age

1 per eye per lifetime

30, for unilateral


45, for bilateral

09.32A

Contact lens fitting (patients 16 yrs & over)

  diagnosis must be keratoconus & diagnostic code 37160 used

  kerotometer reading must be at least 47 diopters in the visual axis

  patient must have at least 5.0 diopters of astigmatism

  corrected vision with spectacles must not be more than 6/12 in the better eye

16 yrs & over

no limitation

83.3, for unilateral


166.6 for bilateral

09.32A

Contact lens fitting

(paitents [patients] under 16 yrs)

  diagnosis must be keratoconus & diagnostic code 37160 used

  kerotometer reading must be at least 47 diopters in the visual axis

  patient must have at least 5.0 diopters of astigmatism

  corrected vision with spectacles must not be more than 6/12 in the better eye

15 yrs & under

no limitation

104.13, for unilateral


208.25, for

bilateral


Tariff of fees

3          The tariff of fees for insured optometric services is as follows:

 

                        (a)       for insured optometric services provided between April 1, 2012, and March 31, 2013, the Medical Services Unit (MSU) is $2.72;

 

                        (b)       effective April 1, 2013, the MSU is increased to $2.76; and

 

                        (c)       effective April 1, 2014, the MSU is increased to $2.80.