Medicaid Restores Payment Levels for Child Vision Services

Thanks to TMA advocacy, Medicaid is restoring physician payments for 50 pediatric eye codes to higher levels paid prior to July 1, 2015. The increase, which takes effect April 1, averages 6.6 percent across all codes.  

For a comparison of fees, see this chart. Several Medicaid HMOs declined to enact the cuts. For HMO payment rates, refer to each plan's fee schedule

For the past nine months, TMA and the Texas Ophthalmological Association (TOA) advocated strongly to restore the payments, meeting with senior officials from Texas Medicaid to urge a special hearing to review the impact of the lower payments on access to care for children. Anecdotal data collected from TMA and TOA indicated the lower payments had a swift and profound negative impact on low-income children's ability to obtain timely vision services. The lower payments resulted in many ophthalmologists making the painful decision to limit or discontinue Medicaid participation. At least one physician practice along the border laid off staff and closed its Saturday clinic to make up for the cuts. 

Medicaid implemented the reduction under a routine review of Current Procedural Terminology (CPT) ophthalmology codes and CPT codes for a dozen other physician services. Medicaid rules require all CPT codes to be reviewed at least once every two years. Reviews can result in decreases, increases, or no change in physician payment.

The pay cuts enacted last year also apply to physician vision services for adult patients. The higher payments taking effect on April 1, however, apply only to children's services. TMA and TOA will continue to vigorously campaign to restore payments for adult services, too. 

Action, April 1, 2016

Last Updated On

May 13, 2016