ELIGIBILITY
Residency
An applicant must be present in the state of Missouri and respond in the affirmative that he/she intends to stay. An applicant must either be a U.S. citizen or be lawfully present in the United States.
Financial Eligibility
Financial eligibility of an applicant is based on the net monthly income available to the household in which the applicant resides. Financial eligibility must be renewed annually, or as needed, to continue receiving POB services.
Definition of household:
All persons living at the same residence, including the applicant, the applicant’s spouse, minor children, and/or parents.
Exception: An adult (18 years or older) who is living with others and is not counted as a dependent by another for income tax purposes may be counted as a separate household.
POB Financial Eligibility Guidelines
| Number in Household | Net Income |
|---|---|
| 1 | $ 645.00 |
For each additional person, add $140.00.
Documentation:
When appropriate, POB staff may request documentation of income as a requirement for service provision.
For self-employed workers and farmers, schedule C or F from the most recent income tax return must be attached to the application form.
Resources:
A household’s resources, including cash or other resources that can reasonably be converted to cash, cannot exceed $3,000.00. The house and attached property owned and lived in or upon by the household is not considered a resource. Vehicles are not considered resources.
Medical Services Resources:
MO HealthNet: MO HealthNet is the program responsible for the administration of services provided in accordance with Title XIX, formerly known as Missouri Medicaid. An individual who is eligible for MO HealthNet services is ineligible for POB services unless:
- It is documented that he/she is in medical need of specific eye-related and POB-covered services not provided by MO HealthNet. POB will provide only those services not covered by MO HealthNet.
- The individual is eligible for MO HealthNet benefits on a spend-down basis, but is ineligible for those benefits until he/she has met the monthly spend-down amount. POB may cover the cost of POB-covered vision care services until the spend-down amount is reached.
Public Institutions: Services will not be provided to persons in public institutions with an eye care program unless the institution has been selected as the location for a POB screening clinic.
Vocational Rehabilitation (VR): If an applicant has an open VR case in an active service status, the applicant is ineligible for POB services.
Exception: The POB coordinator may declare eligibility for services based on the vocational rehabilitation counselor’s plans for imminent case closure and/or the applicant’s needs.
Veteran’s Administration (VA): Services will not be provided to individuals who are eligible for VA services unless they are ineligible for eye care from that resource.
Community Resources: Where established community resources exist for the prevention of blindness and/or provision of vision-related health care, an individual served is ineligible for POB services unless it is documented that he/she is in medical need of specific eye-related and POB-covered services not provided by the community resource. POB only provides services not covered by community resources.
NOTE: This does not apply to programs organized as charity organizations or served primarily by volunteer medical care providers, such as Lions Club and Knights Templar.
Visual Eligibility
Visual eligibility is determined upon receipt of a medical report from an eye care professional, and is based on the following criteria:
- Visual acuity is 20/200 or worse without correction in one or both eyes;
- Malformation of the eye;
- Malfunction of the eye;
- Progressive eye disease; and/or
- Trauma to the eye, even though damage or acuity has not been determined.
Notification of Eligibility Decision
Written notification of the eligibility decision will be provided to the client, signed and dated by the appropriate POB staff member. A copy of the decision will be kept in the client’s file.
Re-Determination of Eligibility:
An application form will be mailed annually to the client. The client will complete, sign, and return the application in a timely manner to POB. Upon receipt of the completed application form, the POB coordinator will determine if the client is eligible for continued POB services. Written notification of the eligibility decision will be provided to the client, signed and dated by the appropriate POB staff member, and a copy will be kept in the client’s file.
REFERRALS
To RSB Programs
Applicants will be screened for potential referral to other RSB programs; however, this will not delay the provision of POB services. A POB client may have a concurrent case with the OBS, ILR or CS programs.
To Other Agencies
In the event an applicant is determined ineligible for POB services, referrals will be made to other programs that may be able to offer assistance.
PROVISION OF SERVICES
Services To Determine Visual Eligibility
Upon verification of financial eligibility, POB will determine visual eligibility. If the client has been examined by a vision professional within the last two years, POB may request a copy of that examination report. If a recent examination report is not available, diagnostic eye examinations to determine visual eligibility may be authorized by POB.
Covered Vision Services Include:
- Surgery and hospitalization, anesthesia, and chest x-rays;
- Medication for treatment of glaucoma;
- Glasses or medically-necessary contacts;
- Follow-up examinations, including those needed to diagnose glaucoma; and/or
- Devices such as artificial eyes and scleral shells to maintain the health of the eyeball or socket as prescribed by a licensed physician.
Limitations Of Services:
- Services are provided if funding allows and may be prioritized.
- Pre-operative tests, including laboratory tests, and preoperative medications are not covered POB services.
- The purchase of glasses and contacts lenses is limited to once every two years unless the client experiences a change in vision greater than .5D (diopter) before the end of the two-year period, in which case only lenses will be replaced. The POB coordinator may approve an exception for documented extenuating circumstances.
FINANCIAL POLICIES
State Departmental Purchasing Procedures:
Staff will follow applicable departmental, divisional, and agency policies and procedures when purchasing services for clients.
Authorization Of Approved Services:
Services are authorized based on the recommendations of licensed eye care professionals. The recommendations should be received before services are provided, except in emergency situations. Services may be covered on the date the client signs the application.
Glaucoma medications are authorized for a six-month period. If an individual ceases to be eligible for POB services or glaucoma medications are no longer needed, the authorization will be cancelled.
A monthly listing of approved clients will be sent to contracted facilities. Eye examinations and procedures covered under the contract do not require specific authorizations for approved clients.
Consideration Of Similar Benefits:
When it has been determined that the client has a medical resource that could meet a covered medical expense, either partially or in total, that similar benefit must be utilized prior to assistance by POB. Similar benefits will be listed on the authorization. If the similar benefit pays more than the established POB rates, POB will not pay further. If the similar benefit pays less than POB rates, POB may pay only the difference not to exceed the POB rate. For Medicare clients, POB may pay co-pays and deductibles up to the POB rate less the Medicare payment.
Consideration of similar benefits is not required if delay of services could result in vision loss.
Payment Rates:
Payments are made based on established POB rates, which are similar to, but not necessarily the same as MO HealthNet rates. POB does not cover all services covered by MO HealthNet. A covered procedure will be paid in accordance with the POB fee schedule. If there is no established POB rate for a covered procedure, either the rate of a similar POB procedure, the MO HealthNet rate or the actual cost may be used, at POB’s discretion.
Utilization of Facilities:
Facilities which have established a contractual agreement with RSB/POB should be utilized when possible. Decisions regarding utilization of contracted facilities will be based on client need and travel distance.
CASE MANAGEMENT
Application Procedures:
- The applicant will complete and sign an Application for Services form and forward it to the POB office. The application is available from POB, RSB, FSD, physicians, health care facilities, and other public and private agencies.
- POB staff will confirm income, resources, similar benefits, and visual eligibility factors.
- The eligibility determination will be made.
- Applicant will be notified of the decision and appeal rights in writing.
Case Closure:
If an applicant is found to be ineligible for POB services, he/she will be notified in writing of the decision. If a client becomes ineligible or no longer desires POB coverage, the case will be closed and the client will be sent written notice of the closure An applicant may reapply for POB services at any time after case closure or receipt of an ineligibility decision.