SECTION 363.502. Benefits and Limitations

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.

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