|(a) Except as specified in §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 §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
(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
(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
(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
(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
(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
(ii) Non-prosthetic eyewear that is lost or stolen
is not reimbursed by the program.
(iii) Repairs to non-prosthetic eyewear are not reimbursable.
|Source Note: The provisions of this §354.1015 adopted to be effective July 1, 1986, 11 TexReg 2750; amended to be effective July 1, 1987, 12 TexReg 1779; amended to be effective March 1, 1990, 14 TexReg 6887; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 1, 2003, 28 TexReg 7285; amended to be effective October 1, 2005, 30 TexReg 6041; amended to be effective April 1, 2010, 35 TexReg 1127; amended to be effectiveDecember6, 2012, 37 TexReg 9493; amended to be effective December 10, 2015, 40 TexReg 8753