TMPPM 2008 > Texas Medicaid Services > Vision Care (Optometrists, Opticians) > Benefits and Limitations

45.4.4 Nonprosthetic Eyewear

Eligible clients may receive nonprosthetic frames and/or lenses once every 24 months. This benefit period begins with the month the glasses are first dispensed. Refer to the Eyeglasses column of the client's Medicaid Identification Form (Form H3087) for determination of eligibility for this service. When there is a change in visual acuity (equal to or greater than 0.5 diopter in one eye), clients are eligible for new nonprosthetic eyeglasses, regardless of when they received their last pair of nonprosthetic eyeglasses or if their Medicaid Identification Form (Form H3087) does not have a check mark (3) in the Eyeglasses column.

The Texas Medicaid Program provides for serviceable eyeglasses, contact lenses that are medically necessary and prior authorized, necessary major repairs to eyeglasses for clients younger than 21 years of age, and replacement of lost/destroyed eyeglasses and contact lenses for clients younger than 21 years of age.

Exception: Diagnosis of aphakia does not require prior authorization.

For clients younger than 21 years of age, there are no limitations on replacements for lost or destroyed eyewear. Eyewear will be reimbursed even if the client's Medicaid Identification Form (Form H3087) does not have a check mark (3) in the services already rendered.

Clients in Medicaid Managed Care health plans may be eligible for additional eyeglass benefits under their plan. Check with the client's health plan for details.

Eyewear must be medically necessary and:

•Prescribed by a physician (doctor of medicine [MD], a doctor of osteopathy [DO]), or an optometrist (OD).

•Prescribed to significantly improve vision or correct a medical condition.

•Must meet the following eyeglass program specifications for frames and lenses:

Frames

•Frames composed of all zynolite components. The frame is the entire piece of eyewear without the lenses.

•Frames composed of a combination of zynolite and metal components are reimbursed to the maximum allowable amount for a zynolite frame. The client may be billed the difference between the reimbursed amount and the billed amount, as the metal portion is not a benefit of the program.

•All metal frames are not a benefit of the Texas Medicaid Program. Clients may be billed for frames that are beyond Medicaid benefits, as specified in "Noncovered Services/Supplies" .

•American-made unless foreign-made frames are comparable in quality and are less expensive.

•Serviceable and able to meet statutory quality standards.

•Composed of new materials.

Eyeglass Lenses

•Clear glass or plastic.

•Heat or chemically-treated dress eyewear able to meet standards of the American Standard Prescription Requirements for first quality glass and plastic lenses.

•Composed of new materials.

•A minimum kryptoc or 22 mm flat top lens or equivalent if bifocal.

•A minimum flat top 7/25 lens or equivalent if trifocal.