1 Tex. Admin. Code § 354.1015 - Benefits and Limitations
(a) Except as
specified in § 354.1023 of this division (relating to Optometric Services
Provider) the services addressed in this subchapter are those optometric
services available to Medicaid recipients who are 21 years old or older.
Services are available to Medicaid recipients under 21 years old through the
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program
described in §
363.502 of this title (relating to
Benefits and Limitations).
(b) The
amount, duration, and scope of optometric services available through the Texas
Medicaid Program are established according to applicable federal regulations,
the Texas state plan for medical assistance under Title XIX of the Social
Security Act, state law, and Texas Health and Human Services Commission (HHSC)
rules. Information regarding benefits and limitations is available to providers
of these services through the Texas Medicaid Provider Procedures Manual issued
to each provider upon enrollment in the Texas Medicaid Program.
(c) The benefits and limitations applicable
to optometric services available through the Texas Medicaid Program to eligible
recipients who are 21 years old or older are as follows:
(1) Provider eligibility. A provider must be
qualified to provide optometric services under Texas Medicaid and enrolled in
the Texas Medicaid Program at the time the service is provided to be eligible
for reimbursement by the program.
(2) Reimbursable services.
(A) Examination. One examination of the eyes
by refraction may be provided to each eligible recipient every 24 months. This
limit does not apply to diagnostic or other treatment of the eye for medical
conditions.
(B) Prosthetic eyewear.
Prosthetic eyewear that meets state and federal specifications, including
contact lenses and eyeglasses (lenses and frames), is a program benefit
provided to an eligible recipient if the eyewear is prescribed for a congenital
abnormality or defect or an acquired condition as a result of trauma or
cataract removal. The following benefits and limitations apply to prosthetic
eyewear:
(i) Medically necessary temporary
lenses are reimbursed during post-surgical cataract convalescence. The
convalescence period is considered to be the four-month period following the
date of cataract surgery.
(ii) Only
one pair of permanent prosthetic lenses may be dispensed as a program
benefit.
(iii) Replacement of
prosthetic eyewear is reimbursed when the eyewear is lost, stolen, or damaged
beyond repair.
(iv) Prosthetic
eyewear is reimbursed when the eyewear is required due to a change in visual
acuity measured in diopters or axis changes as defined by HHSC.
(v) Repairs to prosthetic eyeglasses (lenses
and frames) are reimbursable. Repairs for which the cost of materials is $2.00
or less are the responsibility of the provider and are included in the rate for
eyewear. The provider may not bill the recipient for these services.
(C) Non-prosthetic eyewear.
Non-prosthetic eyewear includes contact lenses and eyeglasses (lenses and
frames) that meet federal and state specifications. Non-prosthetic eyewear is a
program benefit when the eyewear is medically necessary to correct defects in
vision. This eyewear is provided to an eligible recipient only once every 24
months unless the recipient experiences a visual acuity change measured in
diopters or axis changes as defined by HHSC or its designee. A new 24-month
benefit period for eyewear begins with the replacement of non-prosthetic
eyewear due to a change in visual acuity measured in diopters or axis changes
as defined by HHSC or its designee.
(i)
Contact lenses require prior authorization by HHSC or its designee, unless
provided in an emergency. Prior authorization decisions are based on the
provider's written documentation supporting the need for contact lenses as the
only means of correcting the vision defect.
(ii) Non-prosthetic eyewear that is lost or
stolen is not reimbursed by the program.
(iii) Repairs to non-prosthetic eyewear are
not reimbursable.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.