Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 2 - MEDICAID VISION CARE PROGRAM
Section 354.1015 - Benefits and Limitations

Universal Citation: 1 TX Admin Code ยง 354.1015

Current through Reg. 49, No. 38; September 20, 2024

(a) Except as specified in § RSA 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 § RSA 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.

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