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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 4 Vision Care Professionals : 4.3 Services, Benefits, Limitations, and Prior Authorization : 4.3.4 Noncovered Services

4.3.4
The following services and supplies are not a benefit of Texas Medicaid:
Note:
Eyeglasses or contact lenses prescribed or dispensed to clients at a hospital or nursing facility without documented orders of the attending physician in the client’s medical records.
Note:
Optional eyeglass features that are requested by the client but that do not increase visual acuity
(e.g., lens tint, industrial hardening, and decorative accessories or lettering).
Extended color vision examination (procedure code 92283), dark adaptation examination (procedure code 92284), and vision screening (procedure codes 99172 or 99173).
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 (Medicaid Client) 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:
Texas Medicaid may reimburse providers a total of $27.93 for eyeglass frames that are within the provider’s selection for Medicaid reimbursement plus the allowed cost per lens. If the client chooses a pair of frames (such as $200 frames) that are outside of the provider’s selections for Medicaid reimbursement and if the client chooses other items or services that are not a benefit of Texas Medicaid (such as tinted lenses for an extra $10 charge), the client is responsible for and may be billed for the balance of the cost of the frames ($172.07) and the other items that are not a benefit of Medicaid ($10 for 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 or lenses must be refunded to Texas Medicaid. If a client requests eyewear that is beyond program benefits (for example, scratch-resistant coating), 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 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 (Medicaid Client) Certification Form and retain it in the provider’s records.
Note:
A client who has been determined by their provider to have a vision impairment that may require intensive or comprehensive vision impaired related services should be referred to the DARS Division for Blind Services for evaluation and any appropriate resources.

Texas Medicaid & Healthcare Partnership
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