SECTION 355.8461. Reimbursement

The Health and Human Services Commission (HHSC) determines and may adjust the reimbursement rate or methodologies for vision care services according to the provisions as described in §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(1) Examination. Reimbursement for eye examinations is determined in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology)

(2) Eyeglasses. Reimbursement for eyeglasses is based on:

(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 eyewear is provided under competitive procurement, a dispensing fee may be paid to the dispensing provider in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(3) Reimbursement is limited to the type of lenses and frames specified in 25 TAC §33.403 (relating to Specifications for Eyewear). The recipient is not charged for this eyewear.

(4) Eyewear with optional features. If eyewear is not competitively procured, a provider may dispense eyewear with optional features beyond the listed specifications such as special tints, coatings, and other lenses and frame styles selected by the recipient. HHSC reimburses the provider up to the allowable amount for the basic eyewear, and the recipient is responsible for the cost of the optional features selected.

(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 must arrange payment for the optional features with the provider.

(C) The provider may charge the recipient the usual price for the optional features, but may not charge for his professional services.

(5) Contact lenses. Reimbursement for contact lenses, including the handling and dispensing services provided by the supplier, is determined in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(6) Repairs.

(A) Repairs, as described in 25 TAC §33.402(3)(C) (relating to Benefits and Limitations), are reimbursed based on:

(i) the provider's actual cost for supplies plus an allowable handling fee, established by the HHSC and published in the reimbursement rate schedule; or

(ii) a fixed-unit price determined by competitive procurement, as authorized in §354.1025 of this title (relating to Competitive Procurement for Vision Care Services).

(B) Reimbursement for repairs may 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 does not meet the specifications in 25 TAC §33.403 (relating to Specifications for Eyewear).

(7) Eyewear materials and supplies. No reimbursement is made for eyewear materials or supplies, regardless of cost, that do not meet the specifications for eyewear in 25 TAC §33.403 (relating to Specifications for Eyewear).

Source Note: The provisions of this §355.8461 adopted to be effective July 1, 1986, 11 TexReg 2758; amended to be effective June 15, 1988, 13 TexReg 2557; amended to be effective August 1, 1992, 17 TexReg 4695; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred 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