Current through Reg. 49, No. 38; September 20, 2024
In addition to the services specified in §
RSA
354.1023 of this title (relating to
Optometric Services Provider), the benefits and limitations applicable to
vision services available through the Medicaid EPSDT Program are as
follows.
(1) Recipient eligibility.
All Medicaid recipients under the age of 21 are eligible for EPSDT vision
services. Services may be continued through the month the eligible recipient
becomes 21.
(2) Provider
eligibility. All vision services reimbursable by the program must be provided
to eligible recipients by an appropriate provider who is enrolled in the
Medicaid Program at the time the service is provided.
(3) Reimbursable services.
(A) Examination. One examination of the eyes
by refraction may be provided to each eligible recipient:
(i) once every twelve months;
(ii) if there is a significant change in
visual acuity measured in diopter or axis changes, as defined by HHSC;
or
(iii) if the exam is otherwise
medically necessary.
(B)
Eyewear. Eyewear that is medically necessary to correct vision defects may be
provided to an eligible recipient. Eyewear includes eyeglasses (lenses and
frames), contact lenses, and post cataract surgery prosthetic lenses.
(i) Nonprosthetic eyeglasses or contact
lenses are available to an eligible recipient only once every 24 months, unless
the recipient's visual acuity has changed in diopters or axis as defined by
HHSC or the eyewear is lost or destroyed. Except in an emergency, HHSC must
authorize in writing prescriptions for contact lenses before dispensing. Prior
authorization is based on the provider's written documentation that contact
lenses are the only means of correcting the vision defect.
(ii) Prosthetic eyewear is provided to an
eligible recipient if prescribed for post cataract surgery, congenital absence
of the eye lens, or loss of an eye lens because of trauma.
(I) Reimbursement is made for as many
temporary lenses as are medically necessary during post cataract surgery
convalescence (four months after the date of surgery).
(II) Only one pair of permanent prosthetic
eyewear may be dispensed except to replace lost or destroyed prosthetic eyewear
or if required because of a change in visual acuity measured in diopter or axis
changes as defined by HHSC.
(C) Repairs. Eyeglasses repair is
reimbursable if the cost of materials does not exceed the cost of replacement
of the eyeglasses. Repairs costing less than $2.00 are not reimbursable, and
the provider may not bill the recipient for these repairs.
(D) Replacement of lost or destroyed eyewear.
Replacement of eyewear is reimbursable. The date nonprosthetic eyewear is
replaced begins a new 24-month ineligibility period for new eyewear unless the
conditions in subparagraph (B)(i) of this paragraph apply.
(E) Limitations. Eyeglasses and contacts, for
residents of institutions that include these services in their vendor payment,
are not reimbursed under this program.
