A person qualifies for SBP if his visual acuity in the better eye with best correcting lens is not better than 3/60 or 10/200. 55 Pa. Code § 451.3(c)
NOTE: A person whose vision is better than 3/60 or 10/200 may qualify for SBP if he is considered medically blind because of severe tunnel vision. Refer these cases to the Bureau of Policy.
The blind person must have a vision exam by an optometrist or ophthalmologist. See Section 700.41 for instructions on visual acuity. The blind person may choose any practitioner who is enrolled as a provider in the Medical Assistance Program. Vision records on file with the blind person’s eye doctor cannot be used for SB.
Once the CAO finds that the blind person meets visual acuity requirements, the blind person does not need another exam unless the CAO has factual evidence that his vision has improved. For example, the blind person is seen driving a car.
The blind person must report to the CAO any vision improvement that might affect whether he qualifies for SBP. 55 Pa. Code § 451.3(a)(3)
On receiving an SBP application, the CAO must:
1. Determine eligibility except for visual acuity.
2. If the person appears to qualify except for visual acuity, he will make an appointment with the ophthalmologist or optometrist of his choice. The CAO will assist in finding a provider if requested.
NOTE: The blind person does not need a vision exam if both eyes are missing or if he was referred to the CAO by the Bureau of Blindness and Visual Services (BBVS). The CAO must note in the case record that both of the person’s eyes are missing or that BBVS made the referral.
If the blind person and CAO cannot arrange an exam, the CAO must tell the County Medical Consultant the name of the blind person’s doctor and any available medical data on the blind person’s physical or mental condition. The Medical Consultant will tell the CAO what happens next.
If the CAO does not have a Medical Consultant, it will arrange through its Area Manager to use a Medical Consultant from another county or from the Office of Medical Assistance Programs (OMAP). If none is available, the Area Manager will send the information to:
OMAP, Bureau Director of Fee for Service
Harrisburg State Hospital, 1st Floor, Cherrywood Building
P.O. Box 2675
Harrisburg, Pennsylvania 17105-2675
OMAP may ask for information from the ophthalmologist.
3. Give the person an envelope addressed to the examiner with:
Three copies of the report of Ophthalmologic Examination (PA 40)
One copy of the Doctor/Clinic Visit Voucher (MA 440)
An envelope addressed to the CAO
NOTE: The blind person must give the examiner the material from the CAO at the appointment. The examiner will do the exam and return to the CAO two completed copies of the PA 40 and the MA 440.
4. Check the returned PA 40 forms to see that the examiner signed at least one copy. Check to see if the examiner’s statement of visual acuity agrees with the recorded visual acuity. Return the form to the examiner for corrections if it is wrong or incomplete.
5. Send the County Medical Consultant:
Both copies of the PA 40
Any earlier ophthalmologic reports
Any other information in the case record related to visual acuity
NOTE: If BBVS referred the blind person to the CAO and sent a more recent eye exam than the PA 40, the CAO will send the Medical Consultant that exam. The Medical Consultant will review all material and certify whether the blind person’s visual acuity qualifies him for SBP.
6. Authorize SBP if the blind person is found visually eligible and otherwise qualifies.
NOTE: If the blind person is not eligible, authorize an NCE for the date of the exam.
7. Send the MA 440 to:
Department of Public Welfare
Office of Medical Assistance
P.O. Box 8022
Harrisburg, Pa. 17120
The CAO must authorize a visual acuity re-examination when: 55 Pa. Code § 451.3(c)(3)
The Medical Consultant asks for one.
The CAO believes that an SBP recipient’s vision has improved.
NOTE: The CAO does not authorize a re-exam if the recipient recently had refraction, treatment or surgery that improved his vision. In those cases, the CAO must ask for a written report from the District Office of BBVS (if appropriate) or from the recipient's ophthalmologist or clinic.
If the CAO receives the report within one month, it must send the report to the Medical Consultant for review. The Medical Consultant will tell the CAO if the person qualifies for continued SBP or needs a new exam.
If the CAO does not receive the report within one month, it must authorize a re-examination by another ophthalmologist or optometrist. The CAO will send the PA 40 to the Medical Consultant, saying it could not get a report without a re-exam.
When the CAO has good reason to believe the person’s vision has improved enough that he no longer qualifies, it will give notice and suspend benefits until the Medical Consultant confirms that he qualifies.
A person who no longer qualifies because of his visual acuity wants to reapply for SBP and it has been six months since the last eye exam.
NOTE: If less than six months has passed, the CAO may authorize a new exam only with the Medical Consultant’s approval. For approval, the CAO sends the Medical Consultant information showing that the person's vision may have changed since the last exam.
A former SBP recipient who does not qualify for reasons other than visual acuity wants to reapply, and:
It has been at least five years since the last exam, and
He has had eye treatment or surgery since the last exam, or
There is evidence that his vision has improved since the last exam
NOTE: When authorizing a re-exam, the CAO follows the same steps as when authorizing the initial exam. Always submit copies of all PA 40s in the case record along with a report of the current exam and a request for authorization of a reexamination, or asking why a new exam is necessary.
Reviewed July 30, 2013