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

Current through Reg. 49, No. 28; July 12, 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.