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Legislative Report

Legislative Report: TOA Makes Progress on Key Issues in Conjunction With Texas Health and Human Service Commission

From Steve Nguyen, TOA Board Member

NOTE: This article was written before Block Vision's decision to reverse it's policy to require special authorization for patients under four years of age. For more information regarding this change, please see our alert.

Healthcare reform has been on all of our minds. Well, it should-this will affect us all, personally and professionally. While we're waiting on the finished product, let's not forget about the healthcare delivery systems that we currently have. For this article, we will discuss some aspects and changes to Texas Medicaid, and the active role the TOA has taken to address issues and concerns of our membership.

To recap, the TOA was instrumental in amending SB-10 (Medicaid reform bill) during the 80th legislative session. The amendment allows patients, with Texas Medicaid benefits, access to eye care without the need for referral or precertification. Since enactment of SB-10, the reimbursement for many services provided by ODs has increased. The followings are of some changes to reimbursement since enactment of SB-10 : 92004 ($94.51), 92083 ($59.57), 92135 ($67.02), 92250 ($51.27). The Medicaid rate schedule can be found here.

The TOA has been meeting directly with the Texas Health and Human Service Commission (HHSC) on a regular basis to address concerns of our members. Some of the issues we're working to resolve include:

• ICD-9 (diagnosis code) restriction when using Evaluation and Management (E & M) procedure codes
• Exclusion of most CPT codes for same day of service of visit (i.e., fundus photos, vision therapy)
• Polycarbonate lenses for minors
• Management of patients on high risk medications (ie..Plaquenil)
• Medicaid managed care organizations (MCO) requiring referrals, Block Vision requiring pre-certification for patients under 4.

Currently under Texas Medicaid and Healthcare Partnership (TMHP) rules, optometrists are limited to use certain ICD-9 codes when providing/billing for evaluation/management (E&M) procedure codes. Oddly enough, glaucoma and iritis codes are not among this list. The TOA has been working to remove this unnecessary restriction of appropriate diagnosis codes-including testifying to the HHSC Medical Care Advisory Committee and HHS Commissioners Council. TOA is fighting provider discrimination and helping raise awareness of the critical role that Doctors of Optometry fulfill on the front line of eye and vision care.

The TOA has testified at the HHSC rate hearings to support increases in reimbursement to more appropriate levels for many services provided by ODs. Recently, reimbursement for routine eye exams (S0620) and frames (V2020) increased to $65.00/$30.36 respectively. Also, there has been an increase for most high power lenses and proposed changes to allow medically necessary contact lens service and polycarbonate lenses for minors. The list of proposed increased benefits and reimbursement can be found here and here.

TOA has also reported cases of Medicaid MCOs requiring precertification or prior authorization that are in violation of SB-10. Since August 1, Block Vision has required prior authorization request via fax for children under four. Providers are required to obtain separate prior authorization for the exam and glasses, and Block Vision can take up to two days to grant each one. Since our initial communication with Block Vision on this matter, they have reported that prior authorizations have been granted in about an hour in most cases. However, we still believe the eligibility verification process for children under four should be consistent with all children, which is available online or over the phone. We have filed a formal complaint to HHSC and are working with members of the legislature. TOA has coordinated this strong response to fight these "administrative changes" because they place unnecessary barriers to access for your patients.

Remember that volunteer members are taking time out of their offices to help represent you and your patients through the TOA. Please help do your part to keep our organization strong. If you have experienced any cases of insurance discrimination and you can provide proof, please contact your TOA office. Whether it's protecting your scope of practice, access to your patients, or providing member support services, your TOA is constantly working for you ... and the patients that you serve.