Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter J - PURCHASED HEALTH SERVICES
Division 24 - EPSDT: EYEGLASS PROGRAM
Section 355.8461 - Reimbursement

Universal Citation: 1 TX Admin Code ยง 355.8461

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

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

(1) Examination. Reimbursement for eye examinations is determined in accordance with § RSA 355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology)

(2) Eyeglasses. Reimbursement for eyeglasses 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 eyewear is provided under competitive procurement, a dispensing fee may be paid to the dispensing provider in accordance with § RSA 355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(3) Reimbursement is limited to the type of lenses and frames specified in 25 TAC § 33.403(relating to Specifications for Eyewear). The recipient is not charged for this eyewear.

(4) Eyewear with optional features. If eyewear is not competitively procured, a provider may dispense eyewear with optional features beyond the listed specifications such as special tints, coatings, and other lenses and frame styles selected by the recipient. HHSC reimburses the provider up to the allowable amount for the basic eyewear, and the recipient is responsible for the cost of the optional features selected.

(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 must arrange payment for the optional features with the provider.

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

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

(6) Repairs.

(A) Repairs, as described in 25 TAC §33.402(3)(C) (relating to Benefits and Limitations), are reimbursed based on:
(i) the provider's actual cost for supplies plus an allowable handling fee, established by the HHSC and published in the reimbursement rate schedule; or

(ii) a fixed-unit price determined by competitive procurement, as authorized in § RSA 354.1025(3)(C) of this title (relating to Competitive Procurement for Vision Care Services).

(B) Reimbursement for repairs may 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 does not meet the specifications in 25 TAC § 33.403(relating to Specifications for Eyewear).

(7) Eyewear materials and supplies. No reimbursement is made for eyewear materials or supplies, regardless of cost, that do not meet the specifications for eyewear in 25 TAC § 33.403(relating to Specifications for Eyewear).

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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