Updated MCSS Vision Care Fee Schedule Questions and Answers for Service Providers 1. Why are these changes to the Vision Care schedule and Vision Care process being made? There are a number of factors that have led the ministry to update and revise the schedule and process for vision care. The schedules are out of date and feedback received from Optometrists, Opticians, clients and caseworkers confirmed the need to update the schedules regarding services and products available. The new fee schedule includes a basic range of lenses and frames that will meet the needs of most Ontario Disability Support Program (ODSP) clients. Examples of improvements: Proposed schedules are simplified and updated. Obsolete items have been removed. The lenses outlined in the proposed schedule are considered a basic range of lenses. Streamlined and simplified to cover all spectacle necessities without brand names. All service providers are able to use the lens manufacturer of their choice. Price lists are no longer based on prescription powers. This simplifies the pricing and causes less error for claims. Introduction of a new Exceptional Circumstances process will help ensure accountability and integrity of the Vision Care benefit. 2. When will the new schedule be implemented? The new MCSS Vision Care Fee Schedule will go into effect on November 12, 2014. 3. Will clients be required to change their current Vision Care service providers? Social assistance clients will not have to change service providers and will continue to have choice as to who provides vision care service to their family. 1
4. Is there a new Vision Care form that caseworkers are required to provide to clients? A new Vision Care Authorization Form, reflecting the new schedule, has been developed and will be available to recipients through their caseworker via the Social Assistance Management System (SAMS). This form is to be utilized as of November 12, 2014 and will be used in conjunction with the new schedule. The old Vision Care Authorization Form should not be issued to clients by caseworkers after November 10, 2014. 5. A vendor already submitted an invoice before the implementation of the new schedule. Will these invoices/forms be processed? Forms issued before November 10, 2014 will remain valid, as per normal standards, for 30-days after issuance. MCSS will assess and authorize all forms that abide by these standards. Old vision care claim forms issued after November 10, 2014, or not meeting the 30-day standard may be returned to the local office. Caseworkers will then be required to issue a new Vision Care form to the client. 6. How many days does a client have to get their Vision Care Authorization Form completed by a service provider? To avoid a lapse in the validity of the form, service should be provided within 30 days from the date the form is issued by the caseworker. As a reminder, forms are required to be completed and signed by the client s caseworker, the service provider and the client. 7. Are service providers still required to provide verification letters along with the Vision Care Authorization Form for items not covered under the new schedule? Service providers will no longer be required to provide verification letters for items not on the schedule. The Special Circumstances policy will be removed as the new schedule is expected to meet the needs of ODSP clients. An Exceptional Circumstances process will be in place for the updated schedule to ensure that clients receive medically necessary items that are not in the schedule. 2
8. Do service providers still need to request authorization letters from caseworkers for items/amounts not covered under the new schedule? An Exceptional Circumstances process will be in place for the updated schedule to ensure that clients receive medically necessary items that are not in the schedule. Should a client require an item (e.g. contact lenses) that is not covered by the new schedule, the service provider will be required to submit an Exceptional Circumstances Request Form to the Medical Advisory Unit (MAU) at ODSP Branch. Consequently, authorization letters will no longer be required for items not covered under the new schedule. The Special Circumstances policy will be removed as the new schedule has been updated and is expected to meet the needs of ODSP clients. 9. Are service providers expected to provide a copy of a client s prescription information to the client to provide to the caseworker? Yes. Caseworkers are expected to keep a copy of the client s prescription information and file the information in the client s master file. 10. What happens when there is a request for new lenses due to a change in prescription before the replacement period has been met? If a request for new lenses due to a change in prescription is made before the replacement period has been met, prescribers are required to indicate, on the prescription, that a significant change in prescription has occurred. For adults, a significant change in prescription is defined as a change in refractive error of not less than 0.5 diopter to the sphere or cylinder power, or a change in axis equal to or greater than one of the following: 20 degrees for a cylinder power of 0.50 diopters or less; 10 degrees for a cylinder power of more than 0.50 diopters but not more than 1.0 diopter; 5 degrees for a cylinder power of more than 1.0 diopter. Children may receive new lenses anytime there is a change in prescription. The client should provide all relevant information to their caseworker before being issued the Vision Care Authorization Form. 11. Do service providers have to submit requests for contact lenses to the client s caseworker? No. Requests for contact lenses are no longer submitted to the caseworker. If there is a situation where contact lenses are considered a medical necessity, a request for contact lenses may be covered under Exceptional Circumstance 3
process. Both the contact lens fitting fee and contact lens retail cost should be itemized on the Exceptional Circumstance form. 12. What is the Exceptional Circumstances process? An Exceptional Circumstances process will be in place for the updated schedule to ensure that clients receive medically necessary items that are not in the schedule. Decision-making under the Exception Circumstances process will be based on the recommendations of the Medical Advisory Unit who will consult with external vision care experts, as required. The ODSP Director will make the final decision on all exceptions requests. A request for items outside the scope of the MCSS Vision Care Fee Schedule may be made where exceptional circumstances exist. Service providers must obtain pre-authorization from MCSS before providing Exceptional Circumstances services to recipients. All Exceptional Circumstances requests are handled by the Medical Advisory Unit of the ODSP Branch. The service provider must provide the following information: A copy of the Vision Care Authorization Form Completed Exceptional Circumstances Form including: o Description of item/service being requested, and o Rationale for additional service, and o Retail cost of the item/service being requested. Service providers must send their claim form to: Ministry of Community and Social Services Medical Advisory Unit 80 Grosvenor Street, 3rd Floor, Hepburn Block Toronto, ON M7A 1E9 Clients should be advised that the service provider must obtain pre-authorization for items outside the schedule prior to providing the service. 4
13. Where can I find the Exceptional Circumstances Form for the Vision Care Benefit? The Exceptional Circumstances Form will be available on to service providers on the Ontario Shared Service web portal. 14. What is the Medical Advisory Unit (MAU), and what is their role? The MAU is a unit within ODSP Branch. The MAU is responsible for reviewing and making recommendations on exceptional circumstances requests. 15. What is the timeframe for exceptional circumstance claims to be reviewed at the MAU? The MAU will aim to review exceptional circumstances and provide a response within 15 business days. 16. What if a client chooses pay more than $42.20 for frames? Items that do not meet the criteria for the Exceptional Circumstances process and are not listed on the Schedule are the responsibility of the client. The schedule provides a frame allowance of $42.20. If the cost of the frames chosen by the client exceeds the amount in the schedule, the client is responsible for paying the difference in cost directly to the supplier. If a client chooses a high index lens but does not meet the criteria listed in the Schedule (i.e. refractive error is less than +/- 8 diopters), the client is responsible for the difference in cost between the high index cost and the applicable insured lens cost (i.e. CR39 or polycarbonate lens). Service Provider must advise the client that they would have to pay the difference. 17. What is the policy pertaining to replacement of frames due to loss or damage? If a replacement is approved, the current lenses should be placed in the new frames if the existing lenses are satisfactory. If the existing lenses are not satisfactory, or if it is impractical to re-edge the lenses into new frames, new lenses will be authorized. The vision care provider is the party responsible for determining whether the existing lenses are satisfactory for re-edging. 18. Will the ODSP Vision Care Directive and Provincial Business Process be updated to reflect these changes? Both the Directive and Business Process related to Vision Care will be updated. 5
19. With the new process, are clients required to pay for vision care services upfront? In general, clients should be reminded that the ministry will cover certain costs related to vision care (as out lined in ODSP Policy Directive 9.14 and the MCSS Vision Care Fee Schedule) and that these cost will be paid directly to the vision care provider. Clients may pay for items not listed in the schedule. Any additional costs not covered by the schedule must be fully disclosed to, and accepted by, the client prior to the commencement of the service. Service providers may wish to request the funds for the additional costs not covered by the schedule from the client in advance of delivering the service. 20. Will a client be reimbursed by the ministry if they pay the provider for services that otherwise would have been covered by MCSS? No. MCSS can only make payments to optometrists and opticians. Optometrists or opticians are not allowed to directly bill ODSP recipients if the services provided to the client are included in the MCSS Vision Care Fee Schedule. The MCSS cannot pay clients directly, even if the services provided are covered or authorized by the ministry. Should the MCSS become aware of a case where the client has paid the vendor directly and is now seeking reimbursement, the local office will be notified and the client will be advised to contact their caseworker. 21. Where do service providers submit invoices for payment? There is no change in the payment of invoices. The ODSP Vision Care Program is responsible for processing payment for vision care service providers. Invoices should be mailed to: Ministry of Community and Social Services ODSP Vision Care Program 77 Wellesley Street West Box 333 Toronto, ON M7A 1N3 The ODSP Vision Care Unit will not evaluate exceptions or make decisions around exceptions. 6
The ODSP Vision Care Program can only process completed invoices. An invoice will be sent back to the service provider if is not completed, which will delay payment processing. 22. When can a Vision Care provider expect payment? Payments are processed by the ODSP Vision Care Program. The ODSP Vision Care Program will aim to process the invoice within 30 days of receiving the completed form. 23. To ensure timely processing of payment, what documents must be received at the ODSP Vision Care Program? The service provider must provide the following information: A copy of a completed Vision Care Authorization form Copy of the prescription For invoices that include exceptions: A copy of a completed Vision Care Authorization form Copy of the prescription ODSP Director Approved Exceptional Circumstances form including: o Description of item/service being requested, and o Rationale for additional service, and o Cost of the item/service being requested. To avoid delay the Vision Care Program suggests the following; Ensure the form is for ODSP and not Ontario Works All contact information is included on the form and legible Do not send in voided or expired forms 24. How can a Vision Care provider sign-up for Electronic Funds Transfer (EFT)? To sign-up for Electronic Funds Transfer, vision care providers should contact the Ontario Shared Services contact centre at 416-212-2345 or toll free at 1-866- 320-1756 or https://www.doingbusiness.mgs.gov.on.ca/mbs/psb/psb.nsf/en/directdeposit. 25. Who should a vision care provider contact if they have a question regarding the processing of a specific payment? For questions regarding payments ODSP Vision Care Program contacts: Ministry of Community and Social Services ODSP Vision Care Program 77 Wellesley Street West 7
Box 333 Toronto, ON M7A 1N3 SASI-Visioncare@ontario.ca Fax: (647) 723-0343 26. Who should a vision care provider contact if a client refuses completed eyewear or does not pick up the eyewear? The provider should contact: Ministry of Community and Social Services ODSP Vision Care Program 77 Wellesley Street West Box 333 Toronto, ON M7A 1N3 SASI-Visioncare@ontario.ca Fax: (647) 723-0343 27. How can suppliers locate their supplier number? The MCSS Vision Care Program asks that suppliers include their Supplier Number on the ODSP Vision Care Authorization/Invoice forms. The Supplier Number is a unique identifier that helps ensure payments to suppliers are properly directed. The Supplier Number is on all cheque stubs or Electronic Fund Transfer (EFT) statements on payments issued by the Ministry. 8