The Texas Health and Human Services Commission (HHSC) determines
and may adjust the reimbursement rate or methodologies for vision
care services according to the provisions described in §355.8085
of this title (relating to Reimbursement Methodology for Physicians
and Other Practitioners).
(1) Examination. Reimbursement for eye examinations
by refraction is determined in accordance with §355.8085 of this
(2) Eyewear. Reimbursement for prosthetic eyewear is
determined in accordance with §355.8085 of this title and includes
fitting services. Reimbursement for nonprosthetic eyewear is based
(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 §354.1025 of this title (relating to Competitive
Procurement of Vision Care Services). If nonprosthetic eyewear is
competitively procured, a dispensing fee may be paid to the dispensing
provider in accordance with §355.8085 of this title.
(3) Reimbursement is limited to the type of lenses
and frames described in §354.1017 of this title (relating to
Specifications for Eyewear). There is no charge to the recipient for
(4) Optional eyewear features. If eyewear is not competitively
procured, the provider may dispense eyewear with optional features
that include special tints, coatings, and types of lenses and styles
of frames selected by the recipient beyond the specifications of the
Medicaid program. HHSC reimburses the provider up to the allowable
amount for the basic eyewear and the recipient is responsible for
the cost of the optional feature(s) he selects.
(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 is responsible for arranging to pay
the provider for the optional feature(s).
(C) The provider may charge the recipient his usual
price for the selected optional feature(s), but he may not charge
for his professional services.
(5) Contact lenses. Reimbursement for covered contact
lenses, including the handling and dispensing services provided by
the supplier, is determined in accordance with §355.8085 of this
(A) Repairs, as described in §354.1015 of this
title (relating to Benefits and Limitations), are reimbursed at:
(i) the provider's actual cost for supplies plus the
allowable handling fee, published in the reimbursement rate schedule;
(ii) a fixed-unit price determined by competitive procurement,
as authorized in §354.1025 of this title.
(B) Reimbursement for repairs does 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 do not meet the specifications in §354.1017 of this title.
(7) Eyewear materials and supplies. HHSC does not reimburse
for eyewear materials or supplies, regardless of cost, that do not
meet the specifications for eyewear in §354.1017 of this title.
|Source Note: The provisions of this §355.8001 adopted to be effective July 1, 1986, 11 TexReg 2750; amended to be effective June 15, 1988, 13 TexReg 2557; amended to be effective August 1, 1992, 17 TexReg 4694; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; duplicated effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective March 13, 2003, 28 TexReg 2053; amended to be effective December 10, 2015, 40 TexReg 8753