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

45.4.4.5 Noncovered Services/Supplies

The following services and supplies are not benefits of the Texas Medicaid Program:

•All metal frames (for example, frames with all metal structural components; plastic nose pieces or sheathing over ear pieces do not constitute a combination frame).

•Repairs and replacements of lost or destroyed eyewear for clients 21 years of age and older.

•Artificial eyes.

•Plano sunglasses.

•Eyeglasses that do not significantly improve visual acuity or impede progression of visual problems.

•Eyewear prescribed or dispensed to clients at a hospital or nursing facility without documented orders of the attending physician in the client's medical records.

•Eyeglasses for residents of institutions where the reimbursement formula and vendor payment include this service.

•Optional eyeglass features requested by the client that do not increase visual acuity (e.g., lens tint, industrial hardening, decorative accessories, or lettering).

•Prisms that are ground into the lenses.

Clients may be billed for noncovered frames and other items beyond Medicaid benefits.

Providers must have the client sign and date the Vision Care Eyeglass Patient Certification Form and retain it in the provider's records.

The client payment amount is not considered other insurance and must not be entered as a credit amount in the electronic field.

Example: The client wants oversized frames and tinted lenses for a total of $140 ($100 for frames, $30 for lenses, $10 for tinting). Medicaid pays $33.15 for the eyeglasses ($14.45 for the frames and $9.35 per lens, or $18.70 for both lenses). With the Medicaid payment of $33.15, the client may be billed for the balance, which includes the difference between the Medicaid payment for the frames and lenses, plus the $10 charge for the tinted lenses.

The provider may withhold the noncovered eyewear, contacts, or eyeglasses until the client pays for those items. If the client fails to pay for the noncovered items or has not returned for finished eyewear within a reasonable length of time (two to three months), the provider may return any reusable items to stock. Any payment made by TMHP for frames must be refunded to the Texas Medicaid Program. If a client requests eyewear that is beyond program benefits (for example, combination zylonite and metal frames or high-powered lenses), Medicaid allows reimbursement up to the maximum fee. The provider may charge the client the difference between the Medicaid payment and the customary charge for the eyewear requested, when the client has been shown the complete selection of Medicaid-covered eyewear and when the following conditions are met:

•The client rejects the Medicaid-covered eyewear and wants eyewear that complies with Texas Medicaid Program specifications, but is not included in the selection of Medicaid-covered eyewear.

•The client indicates a willingness to pay the difference between the Medicaid payment and the actual charge. The provider must have the client sign the Vision Care Eyeglass Patient Certification Form and retain it in the provider's records.

Providers who advertise "two-for-one" eyeglass special promotions without restrictions may not refuse the offer to clients with Medicaid coverage.

For the purpose of the Texas Medicaid Program, high-powered lenses are defined as those with a sphere greater than 7.00d or a cylinder greater than 4.00d. High-powered lenses are a benefit for clients younger than 21 years of age through THSteps-Comprehensive Care Program (CCP).

Procedure Codes for High-Powered Lenses

Prior authorization is not required for high-powered lenses. The invoice is required and must be maintained in the provider's files. When billing on paper for these services, the invoice must be submitted with the claim and providers are to include a copy of the prescription and manufacturer's suggested retail price. Providers are to use the invoice cost as the billed amount and list the prescription on the claim form, indicating the power is greater than plus or minus 7 diopters or the cylinder is greater than plus or minus 4 diopters. The billed amount should not exceed the invoice amount.

A client who experiences difficulty with daily living activities or employment related to vision may be referred to the Texas Department of Assistive and Rehabilitative Services (DARS). DARS can evaluate the client and may provide resources for assistance, as appropriate.

Modifier RP must be used when billing for replacement lenses. When billing for an adult with diagnosis code 37931, modifier VP must also be billed.

Refer to: The list of offices for the "Department of Assistive and Rehabilitative Services (DARS), Blind Services".

The claim form example, "Vision". Nonprosthetic Eyeglasses and Contacts