Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter J - PURCHASED HEALTH SERVICES
Division 1 - MEDICAID VISION CARE PROGRAM
Section 355.8001 - Reimbursement for Vision Care Services

Universal Citation: 1 TX Admin Code ยง 355.8001

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

The Texas Health and Human Services Commission (HHSC) determines and may adjust the reimbursement rate or methodologies for vision care services according to the provisions described in § RSA 355.8085 of this title (relating to Reimbursement Methodology for Physicians and Other Practitioners).

(1) Examination. Reimbursement for eye examinations by refraction is determined in accordance with § RSA 355.8085 of this title.

(2) Eyewear. Reimbursement for prosthetic eyewear is determined in accordance with § RSA 355.8085 of this title and includes fitting services. Reimbursement for nonprosthetic eyewear is based on:

(A) the unit cost for each pair of eyeglasses rather than costs for components; or

(B)a fixed-unit price determined by competitive procurement, as authorized in § RSA 354.1025 of this title (relating to Competitive Procurement of Vision Care Services). If nonprosthetic eyewear is competitively procured, a dispensing fee may be paid to the dispensing provider in accordance with § RSA 355.8085 of this title.

(3) Reimbursement is limited to the type of lenses and frames described in § RSA 354.1017 of this title (relating to Specifications for Eyewear). There is no charge to the recipient for this eyewear.

(4) Optional eyewear features. If eyewear is not competitively procured, the provider may dispense eyewear with optional features that include special tints, coatings, and types of lenses and styles of frames selected by the recipient beyond the specifications of the Medicaid program. HHSC reimburses the provider up to the allowable amount for the basic eyewear and the recipient is responsible for the cost of the optional feature(s) he selects.

(A) The recipient must sign the claim, or a patient certification, for claims the provider submits electronically to acknowledge selection of eyewear or features beyond program benefits.

(B) The recipient is responsible for arranging to pay the provider for the optional feature(s).

(C) The provider may charge the recipient his usual price for the selected optional feature(s), but he may not charge for his professional services.

(5) Contact lenses. Reimbursement for covered contact lenses, including the handling and dispensing services provided by the supplier, is determined in accordance with § RSA 355.8085 of this title .

(6) Repairs.

(A) Repairs, as described in § RSA 354.1015 of this title (relating to Benefits and Limitations), are reimbursed at:
(i) the provider's actual cost for supplies plus the allowable handling fee, published in the reimbursement rate schedule; or

(ii) a fixed-unit price determined by competitive procurement, as authorized in § RSA 354.1025 of this title.

(B) Reimbursement for repairs does not exceed the replacement cost if the damaged eyewear had been replaced rather than repaired.

(C) No reimbursement is made for repairs to eyewear that do not meet the specifications in § RSA 354.1017 of this title .

(7) Eyewear materials and supplies. HHSC does not reimburse for eyewear materials or supplies, regardless of cost, that do not meet the specifications for eyewear in § RSA 354.1017 of this title.

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