In addition to the services specified in §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.
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| Source Note: The provisions of this §363.502 adopted to be effective July 1, 1986, 11 TexReg 2758; amended to be effective January 1, 1987, 11 TexReg 5058; amended to be effective July 1, 1987, 12 TexReg 1779; amended to be effective October 28, 1987, 12 TexReg 3779; amended to be effective March 1, 1990, 14 TexReg 6888; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2002, as published in the Texas Register December 6, 2002, 27 TexReg 11527; amended to be effective November 4, 2003, 28 TexReg 9521; amended to be effective December6,2012, 37 TexReg 9493; amended to be effective December 10, 2015, 40 TexReg 8754 |
