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RULE §359.509Treatment Services

(a) The purpose of treatment services is to prevent blindness by providing medical or surgical intervention to persons at risk who are not covered under an adequate health benefit plan.

(b) To be eligible to receive treatment services from BEST, a person must be an adult resident of the state who:

  (1) has been referred to the BEST program by the person's treating physician or optometrist;

  (2) has certified to the physician or optometrist that the person does not have health insurance or other available resources with which to pay for prescribed treatment to prevent blindness; and

  (3) has been certified by the physician or optometrist as having a medically urgent eye condition that poses an imminent risk of permanent and significant visual loss if not treated with surgery or medical intervention.

(c) The BEST program is funded with voluntary donations. It is expected that service demand will exceed program resources. Therefore, funds may not be available for treatment services at the time a person is referred for assistance.

(d) If an eligible person is denied services by the BEST program based on the inadequacy of donations to cover the cost of services, the physician may request that the person be placed on a waiting list pending DBS receipt of adequate funds. Persons on the waiting list are served in order by referral date and time.

(e) All treatment services, including prescription drugs, must be approved in advance by the BEST program to qualify for payment. All prescribed treatment services and requested payments must be itemized on the program's application form.

(f) Over-the-counter and nonprescription drugs are not covered by the BEST program. Program assistance with the cost of eye-related drugs prescribed by a physician to prevent blindness is limited to the time the drugs are prescribed by the treating physician or optometrist or one year, whichever is less. The following are the procedures for payment for prescription drugs:

  (1) Payments for approved prescription drugs are made only to the person's pharmacy of choice.

  (2) DBS pays for the prescription upon receiving an invoice.

(g) When the BEST Program pays for a medical or surgical treatment prescribed by a physician as medically necessary for a chronic eye condition such as glaucoma or diabetic retinopathy, the program may pay for no more than two follow-up examinations within the 12 months after the prescribed medical or surgical treatment.

(h) Payments for treatment services are based on DBS' adopted rate schedule for eye-related medical services as specified in Texas Human Resources Code, §117.074 (also known as DBS's Maximum Affordable Payment Schedule).

(i) Claims for payment must be received within 90 days from the date of each service. Claims received by the BEST program that lack the information necessary for processing are denied as incomplete claims. The resubmission of the claim containing the necessary information must be received by the program within 60 days from the last denial date, or payment will be declined. Excepted from this requirement is the payment for refills of drugs prescribed during the allowed period of one year.

(j) The BEST program does not pay cancellation charges, charges for missed appointments, or any other charge incurred other than for the actual provision of services.

Source Note: The provisions of this §359.509 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35

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