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3.3.9 Vision Services for Non-Prosthetic Eyewear
Definition: Non-prosthetic eyewear is medically necessary to correct defects in vision. Providers may refer to TAC §354.1015 for more information.
Limitation for Eye Examination: Clients are eligible for one examination with refraction for the purpose of obtaining non-prosthetic eyewear during each state fiscal year (i.e., September 1 to August 31 according to the vision care annual periodicity schedule) with the following exceptions:
• Clients who are birth through 20 years of age may be eligible for additional exams as outlined in the Eye Examinations section below.
•Eye examinations for aphakia (including congenital aphakia) and disease or injury to the eye may be reimbursed as medically necessary.
Limitation for Eyewear: One pair of eyewear may be reimbursed every 24 months unless the recipient experiences a visual acuity change of 0.5 diopters or more. A new 24-month benefit period for eyewear begins with the replacement of non-prosthetic eyewear due to a change in visual acuity of 0.5 diopters or more.
One pair of conventional eyewear (contact lenses or glasses) may be reimbursed every 24 months for clients who have had cataract surgery with insertion of an intraocular lens (IOL).
The Texas Medicaid vision services benefit includes serviceable non-prosthetic eyeglasses, contact lenses that are medically necessary and prior authorized, necessary major repairs to eyeglasses for clients who are birth through 20 years of age, and replacement of lost or destroyed eyeglasses and contact lenses for clients who are birth through 20 years of age.
Note: Providers who advertise "two-for-one" eyeglass special promotions without restrictions must not refuse the offer to clients with Medicaid coverage.
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