The Health and Human Services Commission (HHSC) adopts amendments to §355.8001, Reimbursement for Optometric Services, and §355.8461, Reimbursement for EPSDT Eyeglass Program. The adopted amendments are pursuant to cost containment strategies identified in the Appropriations Act passed in the 77th Texas Legislature. In accordance with Article II, Special Provisions Relating to Medicaid Cost Containment, Rider 33 (i), the proposed amendments establish a process by which HHSC may competitively procure eyewear in a manner that encourages competition and results in savings to the state.

The amendments are adopted with changes to the proposed text as published in the August 23, 2002, issue of the Texas Register (27 TexReg 7680). In the text of §355.8001 and §355.8461 and the title of §355.8001, HHSC is replacing "optometric services" with "vision care services." HHSC believes that "optometric services" is too limited, as the rules apply not only to optometrists but to opticians and ophthalmologists as well. The use of "vision care services" also conforms these rules to the usage in §354.1025, Competitive Procurement of Vision Care Services, which is being adopted simultaneously in this edition of the Texas Register.

Adopted amendments to §355.8001, Reimbursement for Optometric Services, and §355.8461, Reimbursement for EPSDT Eyeglass Program, will allow HHSC to pay providers a dispensing fee for competitively procured eyewear and add language referencing the adopted new rule, §354.1025, Competitive Procurement of Vision Care Services. Prescribing Medicaid vision providers would order eyewear from contracted vendors and a dispensing fee would be paid to the dispensing provider.

The Texas Optometric Association submitted comments on the proposed rule amendments. In addition, an individual optometrist submitted comments. In general, the comments opposed the procurement of eyewear through a single vendor.

Comment: The Texas Optometric Association (TOA) commented that the proposed rule "will lead to major access issues in many areas. Under the new eyewear proposal, doctors must send a prescription out to a third-party lab and will be unable to provide the patient with lenses immediately. The process of sending all prescriptions to an outside lab will be more inconvenient to most patients." TOA also commented that "If labs are outsourced to a third party, this will severely affect the viability of existing Medicaid practices and may result in a significant reduction of the number of doctors willing to specialize in Medicaid." TOA also commented that the dispensing fee should be adequate to maintain the staff and doctor time it takes to provide the eyewear selections and handling. Similarly, an individual Houston area optometrist commented that changing to a single eyewear lab and paying a dispensing fee would impact eyewear providers' ability to participate in the Medicaid Program. The optometrist also commented that many Medicaid optometrists do the exam and dispense the eyewear in one visit. The commenter stated that under the proposed method, the patient would have to return for the eyeglasses and this would negatively impact patients since many have difficulty with transportation.

Response: Based on the comments, HHSC has withdrawn the Medicaid Vision Eyewear Request for Proposals (RFP). HHSC will not contract with a single eyewear vendor at this time. All enrolled Medicaid vision providers will continue to provide eyewear. HHSC will, however, keep competitive procurement of eyewear as an option available to the Medicaid Vision Eyewear Program. There are no changes to the rules as a result of these comments.

Comment: TOA commented that it is "unclear how long the training program will be, who will do the training, and whether doctors will be given truly adequate time to change their business practices.

Comment: TOA commented that it would be helpful if a prior authorization number were included so doctors cans hop eliminate fraud and abuse by patients who seek more than one examination and additional eyewear at Medicaid's expense.

1. MEDICAID VISION CARE PROGRAM

1 TAC §355.8001

The amendment is adopted under §531.033 of the Government Code, which authorizes the commissioner of health and human services to adopt rules necessary to carry out HHSC's duties under Chapter 531 of the Government Code, and under §32.021 of the Human Resources Code, and §531.021(a) of the Government Code, which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

§355.8001.Reimbursement for Vision Care Services.

The Health and Human Services Commission (HHSC) determines and may adjust the reimbursement rate or methodologies for vision care services according to the provisions described in §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(1) Examination. Reimbursement for eye examinations by refraction is determined in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology)

(2) Eyewear. Reimbursement for prosthetic eyewear is determined in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology) and includes fitting services. Reimbursement for nonprosthetic eyewear is based on:

(A) the unit cost for each pair of eyeglasses rather than costs for components; or

(B) a fixed-unit price determined by competitive procurement, as authorized in §354.1025 of this title (relating to Competitive Procurement of Vision Care Services). If nonprosthetic eyewear is competitively procured, a dispensing fee may be paid to the dispensing provider in accordance with §355.8085 of this title (relating to Texas Medicaid Reimbursement Methodology).

(3) Reimbursement is limited to the type of lenses and frames described in §354.1017 of this title (relating to Specifications for Eyewear). There is no charge to the recipient for this eyewear.

(4) Optional eyewear features. If eyewear is not competitively procured, the provider may dispense eyewear with optional features that include, but are not limited to, special tints, coatings, and types of lenses and styles of frames selected by the recipient beyond the specifications of the Medicaid program. The HHSC reimburses the provider up to the allowable amount for the basic eyewear and the recipient is responsible for the cost of the optional feature(s) he selects.

(A) The recipient must sign the claim, or a patient certification, for claims the provider submits electronically, to acknowledge selection of eyewear or features beyond program benefits.