TABLE G-1 Medicaid Vision Coverage by State
| State | Eligible populationa | Vision benefits covered for children (defined as <21 with exceptions as noted) In addition to the early and periodic screening, diagnostic, and treatment (EPSDT) services for beneficiaries under the age of 21 (with exceptions, as noted); this table lists additional services or stipulations listed by each state’s Medicaid program | Vision benefits covered for adults (in addition to the basic services covered by Medicaid in all states per Medicaid guidelines, e.g., emergency eye treatment as a result of injury. Prosthetic eyes are covered in all states but for >21 in Mississippi and Texas) | Copay required?b |
|---|---|---|---|---|
| Alabamac | Children under age 19 and pregnant woman up to 146% of federal poverty level (FPL) (Alabama Medicaid Agency, 2014). “Children up to 312% of FPL qualify for CHIP (Children’s Health Insurance Program); parents up to 13% of FPL; elderly and disabled individuals with certain medical conditions and income levels” (Norris, 2016a). | Medicaid pays for eye examinations and glasses once every calendar year. Additional covered services may be available if medically necessary (Alabama Medicaid Agency, 2013). | Medicaid pays for eye exams and eyeglasses once every 3 calendar years. Contact lenses may be provided only under certain conditions and when approved ahead of time (Alabama Medicaid Agency, 2013). | $1.30–$3.90 per optometric visit (Alabama Medicaid Agency, 2013). |
| Alaskad | Children up to age 19 are eligible if the family income is up to 203% of FPL, | Between ages 3 and 21, vision screening by an optometrist or an | Medicaid “will cover one vision examination per calendar year by an optometrist or an ophthalmologist to | “$3 for each visit to a health care provider or |
| 177% of FPL if the child is covered by other insurance. Pregnant women with family income are eligible up to 200% of FPL (Alaska Department of Health and Social Services, 2016). “As of September 1, 2015, other adults with family income up to 138% of FPL; blind or disabled individuals who qualify for Alaska Adult Public Assistance” (Norris, 2015a). | ophthalmologist covered in yearly well child exams, as are referrals to vision specialists. Additional vision exams covered if medically necessary. If glasses are required, “Medicaid will pay for one pair of Medicaid-approved glasses per calendar year” (Alaska Department of Health and Social Services, 2012). One additional pair of eyeglasses covered if medically necessary. Any subsequent eyeglasses covered with prior authorization based upon medical justification submitted by provider. Vision therapy services covered (Alaska Department of Health and Social Services, 2012, 2013). | determine if glasses are required and for treatment of diseases of the eye. Medicaid will pay for one pair of Medicaid-approved glasses per calendar year. One company makes all of the eyeglasses for Medicaid. The same eye doctor that gives you a prescription can order your glasses. If you want different frames or a feature that is not covered, you will need to pay the entire cost of the glasses yourself. The amount that Medicaid would have paid cannot be applied to the cost of other glasses. Additional vision coverage may be authorized if medically necessary” (Alaska Department of Health and Social Services, 2012). | clinic” (Alaska Department of Health and Social Services, 2012). | |
| Arizonae | Children under age 1 with family income capped at 147% of FPL. Children ages 1 to 5 with income up to 141% of FPL, and aged 6 to 19 with income up to 133% of FPL (AHCCCS, 2016a). Pregnant women | Vision exams and glasses are covered for children under age 21 (AHCCCS, 2016b,d). Beyond the minimum ESPDT requirement, if/when other procedures or tests are medically indicated, the |
“Treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses, is covered” (AHCCCS, 2016b, pp. 310–314). “Vision examinations and the provision of prescriptive lenses are covered . . . for |
| are eligible with family income up to 156% of FPL; parents and caretakers are eligible up to 106% of FPL; adults under age 65 whose children have coverage are eligible with family income up to 133% of FPL (AHCCCS, 2016a). | physician is obligated to perform them (AHCCCS, 2016c). | adult members when medically necessary following cataract removal” (AHCCCS, 2016b). “Cataract removal is a covered service for all eligible members. Cataract removal is a covered service when the cataract is visible by exam, ophthalmoscope, or slit lamp, and any of the following apply: (1) visual acuity that cannot be corrected by lenses to better than 20/70 and is reasonably attributable to cataract; (2) in the presence of complete inability to see posterior chamber, vision is confirmed by potential acuity meter reading; or (3) for FFS members, who have corrected visual acuity between 20/50 and 20/70, a second opinion by an ophthalmologist to demonstrate medical necessity may be required” (AHCCCS, 2016b, pp. 310–314). “Other cases that may require medically necessary ophthalmic services include, but are not limited to: (1) phacogenic glaucoma and (2) phacogenic uveitis” (AHCCCS, 2016b, pp. 310–315). |
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| Arkansas | “Children from 0 to 18 years with incomes up to 211% of FPL; pregnant women with incomes up to 209% of FPL; parents | One exam and pair of glasses, if necessary, every 12 months. Contact lenses, if medically necessary, are covered but require | One visual examination and one pair of glasses are available to all eligible adult Medicaid beneficiaries every 12 months; lens replacement as medically necessary with prior authorization (and must fit | $2 dispensing fee for prescription eyeglasses for patients ages 21 and older |
| with incomes up to 133% of FPL; non-elderly adults with household incomes up to 133% of FPL; certain elderly and disabled individuals” (Norris, 2016b). | authorization. Vision therapy developmental testing is covered, with prior authorization (ARMedicaid, n.d.). | minimum change criteria); tinted lenses only available for post-op cataract or albino patients (ARMedicaid, n.d.). “A total of twelve (12) office visits allowed per state fiscal year for any combination of the following: certified nurse midwife, nurse practitioner, physician, medical services provided by a dentist, medical services furnished by an optometrist and Rural Health Clinics” (Arkansas Department of Human Services, 2012, p. 7). | (Arkansas Department of Human Services, 2012; ARMedicaid, n.d.; Kaiser Family Foundation, 2012a). | |
| Californiaf | “Children from birth through age 18 with family income levels up to 266% of FPL; pregnant women with incomes up to 213% of FPL; and nonelderly adults—with or without dependent children—with incomes up to 138% of FPL” (Norris, 2015b). | Children “are eligible for a routine eye exam every 24 months, which checks the health of the eyes and tests for an eyeglass prescription. Only members under 21 years old . . . receive coverage for eyeglasses (frames and lenses)” (CDHCS, 2016a). | “All Medi-Cal members are eligible for a routine eye exam every 24 months, which checks the health of the eyes and tests for an eyeglass prescription . . . residents of a nursing home receive coverage for eyeglasses (frames and lenses)” (CDHCS, 2016a). This is limited to one pair of glasses every 2 years. For lost or broken glasses, an interim pair will be covered once in 2 years. “Contact lens testing may be covered if the use of eyeglasses is not possible due to eye disease or condition. Low-vision testing is available for those with vision impairment that is not correctable by standard glasses, contact lenses, medicine |
Some members have a $1 copay, others have no copay (CDHCS, 2016b; HPSM, 2016; Kaiser Family Foundation, 2012b). |
| or surgery and that interferes with a person’s ability to perform everyday activities (e.g., age-related macular degeneration)” (CDHCS, 2016a). “All Medi-Cal members are eligible for a routine eye exam every 24 months, which checks the health of the eyes and tests for an eyeglass prescription . . . residents of a nursing home receive coverage for eyeglasses (frames and lenses)” (CDHCS, 2016a). This is limited to one pair of glasses every 2 years. For lost or broken glasses, an interim pair will be covered once in 2 years. |
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| Coloradog | “Children 0–18 with family incomes up to 142% of FPL; children with family incomes up to 260% of FPL qualify for Child Health Plan Plus (CHP+); pregnant women with family income up to 195% of FPL; pregnant women with family income up to 260% of FPL qualify for CHP+; non-elderly adults | Children’s vision benefits include medically necessary exams and eyewear. Contacts are allowed only if eyeglasses do not correct the refraction error. Future policy may allow orthoptic/pleoptic vision training for children with a diagnosis of convergence insufficiency (Colorado Medical Assistance Program, 2015). | “Adult vision care benefit includes medically necessary eye exams, glasses, and contact lenses only after surgery” (COHCPF, 2016). Does not include orthotic or eye training therapy (COHCPF, 2016). | $2 per visit. Children under 19 and pregnant women do not have copayment (COHCPF, 2016). |
| with family income up to 138% of FPL; some individuals who are elderly or disabled” (Norris, 2015c). | ||||
| Connecticuth | “HUSKY A: Children ages 0–18 with incomes up to 196% FPL; pregnant women with incomes up to 258% FPL; parents of dependent children with incomes up to 155% of FPL (for parents who were already enrolled in HUSKY prior to August 2015 and who have earned income from a job, the household income limit will continue to be 201% of FPL until August 1, 2016). HUSKY B: Children up to 318% of FPL. HUSKY C/MED-Connect: Aged, blind, and disabled beneficiaries who meet income and asset criteria. HUSKY D: Childless adults with incomes up to 138% of FPL” (Anderson, 2015a). |
“Vision care is a covered service that can be done by ophthalmologists, optometrists, and opticians. . . . Eye exams are covered” (Husky Health Connecticut, 2015, p. 16). | “Vision care is a covered service that can be done by ophthalmologists, optometrists, and opticians. . . . Eye exams are covered. For members who are age 21 or older, one (1) pair of eyeglasses will be covered every 2 years. If there has been a serious change in vision and the member needs a new prescription for eyeglasses, they will be covered. No exception will be made for eyeglasses that are lost, stolen, or broken” (Husky Health Connecticut, 2015, p. 16). Special lenses may be covered when specific criteria are met, lenses are considered necessary, and a prior authorization is submitted. | No copay for HUSKY A, C, and D. $15 copay for HUSKY B (Husky Health Connecticut, 2016). |
| Delawarei | “Children birth to 1 year with family income up to 212% of FPL; children 1–5 years with family income up to 142% of FPL; children 6–18 with family income up to 133% of FPL; pregnant women with family income up to 212% of FPL; parents with family income up to 138% of FPL; childless, non-elderly adults with family income up to 138% of FPL; elderly and disabled individuals with special requirements and who meet certain income limits. Children 1–18 up to 212% of FPL are covered through the Healthy Children” (Anderson, 2015b). | Lenses and frames covered when medically necessary. The Delaware Medical Assistance Program (DMAP) will cover the replacement of damaged lenses and/or repair broken frames. The DMAP may cover contact lenses to correct a medical condition if the medical condition is not correctable with eyeglasses. This service must be prior authorized (DMAP, n.d.). | Routine eye care and glasses are not covered except for aphakic or bandage lenses necessary after cataract surgery. Examination limited to the diagnosis and treatment of medical conditions (DMAP, 2016). | None |
| District of Columbiaj | “Children 0–18 with incomes up to 319% of FPL; pregnant women with incomes up to 319% of FPL; parents with dependent children with incomes up to 216% of FPL; other nonelderly adults with incomes up to 210% of FPL” (Anderson, 2015c). | One pair of eyeglasses covered every year. A minimum diopter correction is required. Repairs or replacements covered if medically necessary (DHCF, 2016). | If medically necessary, DC Medicaid pays for 1 pair of glasses every 2 years. A minimum diopter correction is required (DHCF, 2012, 2016). | $2/dispensing service for glasses (Kaiser Family Foundation, 2012a). |
| Florida | “Children up to 1 year old with family income up to 206% of FPL; children 1–5 with family income up to 140% of FPL; children 6–18 with family income up to 133% of FPL; pregnant women with family income up to 191% of FPL; young adults 19–20 with family income up to 30% of FPL; adults with dependents with family income up to 30% of FPL. People who qualify for Supplemental Security Income automatically qualify for Medicaid” (Norris, 2015d). | Eyeglasses are limited to two pairs of glasses per enrollee (under age 21) per year. Contact lenses are limited to “when the recipient has a documented medical condition where eyeglasses would not provide any benefit for their visual impairment” (Florida Agency for Health Care Administration, 2015, p. 3). Other services for enrollees under age 21 covered if approved and medically necessary (Florida Agency for Health Care Administration, 2015). | Eyeglasses are limited to one frame per enrollee every 2 years and two lenses per enrollee per year (Florida Agency for Health Care Administration, 2015). “Contact lenses are limited to Enrollees who have unilateral aphakia or bilateral aphakia” (Florida Agency for Health Care Administration, n.d., p. 6). Polycarbonate or thermoplastic lenses covered for safety, or when medically necessary. Metal frames are covered when medically necessary. Eyeglass repair is covered except for when cost exceeds that of new eyeglasses (Florida Agency for Health Care Administration, 2015). “Only elements of the frames or lenses that are damaged beyond repair may be replaced” (Florida Agency for Health Care Administration, 2015, p. 3). |
$2/visit for optometrist visits (Kaiser Family Foundation, 2012b). |
| Georgiak | “Children up to age 1 with family income up to 205% of FPL; children 1–5 with family income up to 149% of FPL; children 6–18 with family income up to 133% of FPL; pregnant women with family income up to 220% of FPL; parents with family income up to 35% of FPL; individuals who are elderly, blind, or disabled” (Anderson, 2015d). | Eye exams and eyeglasses are covered once per year. Second exams covered with prior approval, second glasses covered with minimum diopter change. Polycarbonate lenses covered if medically necessary. Contact lenses covered with prior approval. Replacement | Eyeglass coverage is limited to nursing facility residents with physician referral. Adults are not eligible for eyeglasses, refractions, dispensing fees, and other refractive services. Members can receive medical diagnostic and treatment services for ocular disease. Vision therapy is covered with prior approval (Georgia DCH, 2016). | $0.50–$3/optometrist visit (Georgia DCH, 2016; Kaiser Family Foundation, 2012b). |
| of broken glasses covered with prior approval. Replacement of lost eyeglasses not covered. New lenses must improve visual acuity by at least one line on a standard acuity chart. Vision therapy covered with prior approval (Children’s Vision Georgia, 2013; Georgia DCH, 2016). | ||||
| Hawaiil | “Children with family income levels up to 308% of FPL. Pregnant women with family income up to 191% of FPL. Adults with family income up to 133% of FPL” (Norris, 2015e). | Eyeglasses and a routine eye exam by an optometrist are covered once every 12 months for those age 20 and under. More frequent exams covered if medically necessary with prior authorization (Hawaii Department of Health, 2011a). | Eyeglasses and a routine eye exam by an optometrist are covered once every 24 months. More frequent exams covered if medically necessary with prior authorization. Prescription lenses and cataract removal covered for all members (Hawaii Department of Health, 2011a). Non-covered services include “tinted lenses (except in the case of aphakia); contact lenses for cosmetic purposes; bifocal contact lenses; oversized lenses; blended or progressive bifocal lenses; tinted or absorptive lenses (except for aphakia, albinism, glaucoma, medical photophobia); trifocal lenses (except as a specific job requirement); spare glasses” (Hawaii Department of Health, 2011b, p. 3) |
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| Idaho | “Children ages 0–5 with family income up to 142% of FPL. Children ages 6–18 and pregnant women with | One eye examination during any 12-month period by a physician or optometrist to determine need for glasses. | Services necessary to treat or monitor a chronic condition, such as diabetes, that may damage the eye; and acute conditions that if left untreated may cause permanent | “$3.65/visit, up to 5% of income/year across all services” |
| family income up to 133% of FPL. Parents with family income up to 124% of FPL . . . additional eligibility criteria for individuals who are aged or disabled” (Noris, 2016c). | Following a diagnosis, eyeglasses are covered, one pair every 4 years except if there is documentation of a major visual change (Idaho Department of Health and Welfare, 2009). “Scratch resistant coating is required for all plastic and polycarbonate lenses” (Idaho Department of Health and Welfare, 2009). Tinted lenses only covered with a diagnosis of albinism or other extreme medical condition. Contact lenses covered in extreme conditions when eyeglasses are not medically sufficient. Replacement of broken or lost frames is not covered (Idaho Department of Health and Welfare, 2009). | or chronic damage to the eye (Idaho Department of Health and Welfare, 2009). | (Kaiser Family Foundation, 2012b). | |
| Illinois | “Children ages 0–18 with family income levels up to 142% of FPL. Pregnant women with family income up to 208% of FPL. Adults with family income up to 133% of FPL” (Anderson, 2016). | “One routine eye exam each year. . . . One pair of [eye]glasses every year for members under age 21. Medically necessary contact lenses. Replacement glasses [covered] for members aged 19 and 20 as needed” (Aetna, 2016). | “Diagnosis and treatment of medical conditions of the eye (may be provided by an optometrist operating within the scope of his or her license)” (Illinois Department of HFS, 2009, p. 38). One pair of glasses covered every 2 years (Illinois Department of HFS, 2012). “Replacement lenses [covered] for members ages 21 and older, when medically necessary. One | $3.65/visit to an optometrist (Kaiser Family Foundation, 2012b). |
| replacement pair of [eye]glasses each year if the first pair of [eye]glasses is lost or broken beyond repair” (Aetna, 2016). One routine eye exam covered each year (Aetna, 2016; Illinois Department of HFS, 2012). | ||||
| Indianam | “Children up to 1 year with household income up to 208% of FPL. Children ages 1–18 with household income up to 158% of FPL. Pregnant women with household income up to 208% of FPL. Adults with incomes up to 138% of FPL can enroll in HIP 2.0” (Norris, 2015f). | “One routine vision care examination and refraction for members 20 years old and younger, per rolling calendar year” unless more frequent care is medically necessary (IHCP, 2016). Coverage for eyeglasses, including frames and lenses, is limited to a maximum of one pair per year except when a specified minimum prescription change makes additional coverage medically necessary or the member’s lenses and/or frames are lost, stolen, or broken beyond repair (IHCP, 2016). Tinted and polycarbonate lenses covered when medically necessary (IHCP, 2016). | The standard Medicaid plan is limited to one vision examination and refraction every 2 years for members ages 21 and older, unless more frequent care is medically necessary (IHCP, 2016). Coverage for eyeglasses, including frames and lenses, is limited to a maximum of one pair every 5 years. Exceptions are when a specified minimum prescription change makes additional coverage medically necessary or the member’s lenses and/or frames are lost, stolen, or broken beyond repair (IHCP, 2016). Tinted and polycarbonate lenses covered when medically necessary (IHCP, 2016). | |
| Iowan | “Children up to age 1 with family income up to 375% of FPL. Children ages | Eye exams covered once every 12 months and more often if there are complaints | Eye exams covered once every 12 months and more often if there are complaints or symptoms of eye disease or injury. | $2/day for optometrist or optician services |
| 1–18 with family income up to 167% of FPL; children with family income up to 302% of FPL may qualify for the Hawk-I program. Pregnant women with family income up to 375% of FPL. Adults with family income up to 133% of FPL” (Norris, 2016d). | or symptoms of eye disease or injury. Contact lenses covered following cataract surgery or other extreme conditions when vision cannot be corrected with glasses. New frames covered three times for children up to 1, four times for children 1–3. One time every 12 months for children ages 4 to 7. Once every 24 months after the age of 8. Repairs and replacement frames are covered with no limit. Vision therapy covered when medically necessary. Polycarbonate lenses and safety frames covered for children through 7 years and when medically necessary (Iowa Department of Human Services, 2014). | Glasses covered once every 24 months. Contact lenses covered following cataract surgery or other extreme conditions when vision cannot be corrected with glasses. Replacement of lost or damaged glasses is covered once every 12 months except when member has mental or physical disability. Vision therapy covered when medically necessary. Polycarbonate lenses and safety frames covered when medically necessary (Iowa Department of Human Services, 2014). | (Kaiser Family Foundation, 2012a,b). | |
| Kansas | “Children up to age 1 with family income up to 166% of FPL. Children ages 1–5 with family income up to 149% of FPL. Children ages 6–18 with family income up to 133% of FPL; children with family income up to | Prescription drugs, medical care by doctors, and eyewear coverage are included for most people (KanCare, 2012). “One complete eye exam covered every 4 years . . . however a total of two eye exams are covered per month to detect |
$2/date of service for glasses; $2/date of service for visits (Kaiser Family Foundation, 2012a,b). |
| 242% of FPL are eligible for CHIP. [Additional eligibility guidelines for] individuals who are elderly or disabled” (Norris, 2015g). | and/or follow medical conditions. . . . Refraction is not included in a basic eye exam” (KHPA, 2010, p. 8-3). Eyeglasses are covered with certain limitations, polycarbonate lenses are covered when considered medically necessary. Contact lenses are covered upon approval through a prior authorization (KHPA, 2010). Kansas provides Medicaid coverage through three managed care organizations (MCOs), all of which cover eyeglasses. One of the MCOs (United Healthcare) has more expansive benefits, stating coverage for a “better choice of eyeglass frames . . . replacement if glasses are lost or stolen” and possibly contact lenses for some members (KanCare, 2016). |
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| Kentuckyo | “Children up to age 1 with family income up to 195% of FPL. Children ages 1–18 with family income up to 159% of FPL; children with family income up to 213% of FPL are eligible for the Kentucky Children’s Health Insurance Program. Pregnant women with family income up to 195% of FPL. Adults with income up to 133% of FPL” | New patient eye exams limited to one every 3 years, established patient eye exams limited to one every 12 months. Physician office visits limited to two every 12 months per diagnosis. Eyeglasses covered up to $200 for Global Choice members and up to $400 for Family Choice, Comprehensive Choice and Optimum Choice members. | New patient eye exams limited to one every 3 years, established patient eye exams limited to one every 12 months. Physician office visits limited to two every 12 months per diagnosis. Eyeglasses are not covered. Contact lenses are not covered (Kentucky CHFS, 2007). | $3/visit for adults, $0/visits for children (Commonwealth of Kentucky, n.d.). |
| (Norris, 2015h). Workers with disabilities up to 250% of FPL (Kentucky CHFS, 2015). | Tinted lenses covered with diagnosis of photophobia. Contact lenses not covered (Kentucky CHFS, 2007). | |||
| Louisianap | “Children ages 0–18 with household income up to 212% of FPL; kids with family income between 212% and 250% of FPL are eligible for the Louisiana Children’s Health Insurance Program. Pregnant women with household income up to 133% of FPL. Parents with dependent children with household income up to 19% of FPL. . . . [There are other qualifications for] those who receive SSI or who are elderly, blind, or disabled” (Norris, 2016e). | “Examinations and treatment of eye conditions, including examinations for vision correction [and] refraction error. Regular eyeglasses are covered when they meet a certain minimum strength requirement. Medically necessary specialty eyewear and contact lenses can be covered with prior authorization. Contact lenses are covered if they are the only means for restoring vision. Other related services may be covered if medically necessary” (Louisiana Medicaid, 2016, p. 18). | “Examinations and treatment of eye conditions such as infections and cataracts are covered” (Louisiana Medicaid, 2016, p. 18). If the recipient has both Medicare and Medicaid, some vision-related services may be covered. “The recipient should contact Medicare for more information since Medicare would be the primary payer. . . . Non-covered services include routine eye examinations for vision correction . . . [and] refraction error [as well as] eyeglasses” (Louisiana Medicaid, 2016, p. 18). | Medicaid may pick up a calculated portion of the payment as a Medicare crossover claim.p |
| Maine | “Children up to 1 year old with household income up to 191% of FPL. Children ages 1–18 with household income up to 157% of FPL; children with family income up to 208% of FPL qualify for the Children’s Health | One annual routine eye exam covered (Maine DHHS, 2012). “Contact lenses [are covered] only for treatment of ocular pathology, or for cases in which acuity is not correctable to 20/70 with | One routine eye exam covered every 3 rolling calendar years, unless specific medical diagnoses warrant more frequent examination (Maine DHHS, 2012). Contact lenses not covered. “One pair of eyeglasses per lifetime is covered when the power is equal to or greater than 10.00 diopters” (Maine DHHS, 2012, p. 5). | $0.50–$2/day of service for glasses; up to $20/month if service is provided by an optician (Kaiser Family |
| Insurance Program; 19- and 20-year-olds with household income up to 156% of FPL; pregnant women with household income up to 209% of FPL; parents and other caretakers with household income up to 100 percent of FPL” (Anderson, 2015e). | ophthalmic lenses, but can be improved to 20/70 or better with contact lenses” (Maine DHHS, 2012, p. 4). Eyeglasses covered when the refractive error in at least one eye meets a minimum requirement, with prior authorization. Replacement frames and repairs covered (Maine DHHS, 2012). Glasses must be purchased through the state contractor. Tint, photochromatic, or ultraviolet (UV) lenses covered when medically necessary. Orthoptic therapy covered with prior authorization when medically necessary (Maine DHHS, 2012). | Replacement frames and repairs covered. Glasses must be purchased through the state contractor. Tint, photochromatic, or UV lenses covered when medically necessary. Orthoptic therapy covered with prior authorization when medically necessary (Maine DHHS, 2012). | Foundation, 2012a). Visits may require a copay between $0.50 and $3 per visit, up to $30 per month (Kaiser Family Foundation, 2012b). | |
| Marylandq | “Children ages 0–21 with household income up to 317% of FPL. Pregnant women with household income up to 250% of FPL. Adults with household income up to 133% of FPL. Aged, blind, or disabled individuals” (Anderson, 2014). | One pair of glasses covered every year if medically necessary. Replacement eyeglasses covered. One eye exam covered every year (Maryland DHMH, 2014). | Eye examination covered every 2 years. Glasses are not covered (Maryland DHMH, n.d.). |
| Massachusetts | “Children up to 1 year with household income up to 200% of FPL. Children ages 1–18 with household income up to 150% of FPL. Pregnant women with household income up to 200% of FPL. Adults with household income up to 133% of FPL” (Anderson, 2015f). | Comprehensive eye exams covered once every 12 months. More often if medically necessary. One pair of eyeglasses covered. New pair covered with a specific change in prescription. Replacement glasses covered, but only covered within the first 12 months with prior authorization. Eyeglass repairs covered. Tinted lenses and contact lenses covered if medically necessary (MassHealth, 2008). | Comprehensive eye exams covered once every 24 months. More often if medically necessary. Replacement glasses covered, but only covered within the first 12 months with prior authorization. Eyeglass repairs covered after the first 12 months. Tinted lenses and contacts covered if medically necessary (MassHealth, 2008). | |
| Michiganr | “Children up to 1 year with household income up to 195% of FPL. Children ages 1–18 with household income up to 160% of FPL; children with household income up to 212% of FPL qualify for MICHILD (low-cost health insurance for kids). Pregnant women with household income up to 195% of FPL. Adults with household income up to 133% of FPL” (Anderson, | “Corrective lenses and/or frames are covered if determined to be medically necessary by a licensed optometrist or ophthalmologist. Determination of medical necessity is based on specific diopter criteria and/or concurrent complicating medical conditions. . . . Two pairs of replacement eyeglasses or contact lenses in a year for recipients | One eye exam is covered every 24 months to determine the prescription for corrective lenses. Vision therapy is covered for limited clinical conditions (MDHHS, 2016, p. 25). “Corrective lenses and/or frames are covered if determined to be medically necessary by a licensed optometrist or ophthalmologist. Determination of medical necessity is based on specific diopter criteria and/or concurrent complicating medical conditions. . . . One pair of replacement eyeglasses or contact lenses in a year for recipients age 21 and over” is covered | $2/date of service for glasses; $2/visit (Kaiser Family Foundation, 2012a,b). |
| 2015g). Aged, blind, or disabled individuals are also eligible (State of Michigan, 2016). | under age 21. Prior authorization is required for eyeglasses that exceed the replacement limits” (MDHHS, 2016, p. 25). | without prior authorization (MDHHS, 2016, p. 25). “Prior authorization is required for eyeglasses that exceed the replacement limits” (MDHHS, 2016, p. 25). | ||
| Minnesota | “Children up to 1 year with household income up to 283% of FPL. Children ages 1–18 with household income up to 275% of FPL. Pregnant women with household income up to 278% of FPL. Adults with household income up to 138% of FPL; adults with income between 138% and 200% of FPL qualify for MNCare” (Norris, 2015i). | “Deluxe eyeglass frames . . . for children” (Minnesota DHS, 2016). “Visual therapy for amblyopia is limited to children under 10 years old. If improvement is not noted after four sessions, the recipient must be referred to an appropriate professional (for example, neurologist or ophthalmologist) for further evaluation” (Minnesota DHS, 2016). |
Eye exams are covered without copay; eyeglasses are covered without cost sharing, limited to one pair every 2 years unless lost, broken, or stolen (Minnesota DHS, 2013). Tinted, UV, polarized and photochromatic lenses covered if medically necessary (Minnesota DHS, 2016). Contact lenses covered with medically necessary diagnosis or with prior authorization (Minnesota DHS, 2016). | $3/optician visit, or $25/pair of glasses (Kaiser Family Foundation, 2012a). Higher copay is for beneficiaries in “Group B”; parents and caretakers with income up to 215% of FPL. $3/visit required for a non-preventive service (Kaiser Family Foundation, 2012b). |
| Mississippi | “Parents with dependent children are eligible with household incomes up to 22% of FPL. Children are eligible for Medicaid | “2 pairs of eyeglasses per year [for] EPSDT-eligible beneficiaries. Eligible for more services if medically necessary” (Mississippi | “One complete pair of eyeglasses per 5 years. . . . This includes eyeglass lenses and frames. Repairs and replacements not covered. . . . Tinted, photochromatic or UV protected lenses [covered] when | $3/pair of eyeglasses; $3/visit, limited to 12 per year (Mississippi |
| or CHIP with household incomes up to 209% of FPL, and pregnant women are eligible with household incomes up to 194% of FPL” (Norris, 2015j). | Division of Medicaid, 2016). | medically necessary” (Mississippi Division of Medicaid, 2014, p. 7). One eye examination by optometrist or ophthalmologist every 5 years. Contact lenses provided for specific disease or injury (Mississippi Division of Medicaid, 2014). | Division of Medicaid, 2016). | |
| Missouri | “Parents with dependent children are eligible with household incomes up to 18% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 300% of FPL, and pregnant women are eligible with household incomes up to 196% of FPL” (Healthinsurance.org, 2015a). | One eye exam covered per year (MO HealthNet, 2016). Frames covered once every 24 months. Lenses covered if medically necessary or required for school performance once every 2 years. Photochromatic, tinted, and polycarbonate lenses covered when medically necessary. Replacement of broken or lost frames and/or lenses covered when glasses are necessary for school with prior approval. Orthoptic and/or pleoptic training covered when medically necessary (MO HealthNet, 2016). | One eye exam allowed per 2 years, allowed every year for the blind, pregnant women, and nursing home residents (MO HealthNet, 2016). Frames covered once every 24 months. Lenses covered if medically necessary once every 2 years. Photochromatic, tinted, and polycarbonate lenses covered when medically necessary. Replacement frames not covered unless significant change in diopter. Orthoptic and/or pleoptic training covered when medically necessary (MO HealthNet, 2016). | $0.50–$3/service for glasses or visit (Kaiser Family Foundation, 2012a,b). |
| Montanas | “Parents 50–138% of FPL and childless adults with incomes up to 138% of FPL” (Kaiser Family | Eye exams are covered. One exam per year, unless medically necessary. Glasses providers | One eye exam every 12 months unless vision changes significantly, or for treatment of eye disease (Montana DPHHS, 2016). Glasses providers must show | $3/service for the Healthy Montana Kids/CHIP program members. |
| Foundation, 2015, p. 3). Pregnant women with incomes up to 157% of FPL; children are eligible for Medicaid or CHIP with incomes up to 261% of FPL (Norris, 2016f). | special frames approved by Medicaid, which are covered, with a 24-month warranty. One pair of glasses covered every 365 days, but most add-ons, including photo-grey lenses, are not covered (Montana DPHHS, 2013, 2016). | must show special frames approved by Medicaid, which are covered, with a 24-month warranty. Most add-ons, including photo-grey lenses, are not covered (Montana DPHHS, 2013). | Effective June 1, 2016, $4/service for Medicaid program including the expansion-HELP program (Montana DPHHS, 2016). | |
| Nebraskat | Parents with dependent children are eligible with income up to 58% of poverty. Pregnant women with income up to 194% of poverty (Nebraska DHHS, 2016). Children 0–1 with income up to 162% of poverty, ages 1–5 up to 145% of poverty, ages 6–18 up to 133% of poverty (Nebraska DHHS, 2016). CHIP is up to 213% of poverty (Nebraska DHHS, 2016). Adults that meet criteria for the aged, blind, and disabled with income up to 100% of the poverty level. | Eye exams covered annually. More frequent eye exams covered if medically necessary. Vision therapy covered when medically necessary (NMAP, 2003). | “Eye examinations to determine the need for glasses, the purchase of glasses, and necessary repairs. . . . Eye exams for adults 21 years and older are limited to one every 24 months. . . . Eyeglasses including lenses and frames are covered when required for medical reasons” (Nebraska Medicaid Program, 2014). Repairs covered when less costly then new frames. Contact lenses covered when medically necessary. Vision therapy training covered when medically necessary. Polycarbonate, tint, and UV frames covered when medically necessary. (NMAP, 2003). | $2/pair of glasses or visit (Kaiser Family Foundation, 2012a,b). |
| Nevadau | “The aged, blind, and disabled. Also, coverage is available if your household | “Vision screenings as referred by any appropriate health, developmental, or | “Refractive examinations performed by an optometrist or ophthalmologist are covered for Medicaid recipients of all ages | None |
| income is up to 138% of poverty (about $16,105 for a single person). For pregnant women, income can be up to 160% of FPL, and children are eligible for CHIP with household income up to 200% of poverty” (Norris, 2015k). | educational professional after a Healthy Kids Screening Exam. Optometrists and ophthalmologists may perform such exams without prior authorization upon request or identification of medical need. “Medical Need” may be identified as any ophthalmological examination performed to diagnose, treat, or follow any ophthalmological condition that has been identified. . . . Glasses may be provided at any interval without prior authorization for EPSDT recipients, as long as there is a change in refractive status from the most recent exam, or for broken or lost glasses” (DHCFP, 2015, p. 7). | once every 12 months. Any exceptions require prior authorization” (DHCFP, 2015, p. 7). Lenses are covered with prior authorization. Vision therapy covered with prior authorization (DHCFP, 2015). | ||
| New Hampshirev | Adults with household incomes up to 133% of poverty, and pregnant women with incomes up to 196% of poverty. Children age 1–18 are eligible for Medicaid with a household | Same as adults except that replacement of lost glasses is covered once in a lifetime (New Hampshire Medicaid, 1994, 2013). | Fee-for-service (FFS) as well as via two separate MCOs, which offer the same coverage as FFS. One MCO (NH Health Families) offers a vision credit if someone opts for frames outside of standard benefits (New Hampshire Medicaid Care Management, 2015). |
| income up to 196% FPL. Children aged 0–18 are eligible for CHIP with household incomes >196% FPL and up to 318% of poverty. In addition, individuals are covered on the basis of being elderly, blind, or disabled (Norris, 2016g). | “One complete eye exam [covered] every 12 months to determine the need for glasses. When certain prescription requirements are met, one pair of single vision glasses; or one pair bifocal glasses or one pair each reading and distance glasses. Replacement glasses only when vision changes of 1/2 diopter or more occur in each eye. One repair of glasses per year— replacement of broken parts only” (New Hampshire Medicaid Client Services, 2014, p. 1). “Contact lenses [are covered] for ocular pathology in cases where visual acuity is not correctable to 20/70 or better without contact lenses, or when required to correct aphakia or to treat corneal disease” (New Hampshire Medicaid, 2013, p. 4). Transition lenses covered for recipients with ocular albinism (New Hampshire Medicaid, 2013). Trifocal lenses for work. Eye exams covered “to diagnose and monitor medical conditions of the eye” (New Hampshire Medicaid, 2013, p. 4). | |||
| New Jersey | “The aged, blind, and disabled. Also, adults with income up to 138% of poverty, and pregnant women with income up to 200% of poverty. Children are eligible for Medicaid or CHIP with income up to | “Age 18 and under . . . replacement eyeglasses or contact lenses annually if prescription changes. . . . Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes | “[Age] 60 and older—Replacement eyeglasses or contact lenses annually if prescription changes. Age 19 to 59—Replacement eyeglasses or contact lenses every two years if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. Contact | $5.00 per office visit for Plan C and Plan D members (New Jersey DMAHS, 2004). |
| 350% of poverty (Norris, 2014a). | occur. Contact lens exams and fittings are covered only when deemed medically necessary over glasses. . . . Cover[age applies to] one routine eye exam per year” (Horizon NJ Health, 2014, p. 21). | lens exams and fittings are covered only when deemed medically necessary over glasses. . . . Cover[age applies to] one routine eye exam per year” (Horizon NJ Health, 2014, p. 21) “Members with diabetes can have an eye exam every year, which should include a dilated retinal eye exam” (Horizon NJ Health, 2014, p. 17). |
||
| New Mexicow | “The aged, blind, and disabled. Also, adults with income up to 138% of poverty. Pregnant women are eligible for pregnancy-related coverage with household income up to 250% of poverty. Children are eligible for CHIP with income up to 240% of poverty (ages 7–18) or 300% of poverty (ages 0–6)” (Norris, 2015l). | Limited to one routine eye exam per year unless otherwise medically necessary. One frame and one set of corrective lenses covered per year; “more frequently when an ophthalmologist or optometrist recommends a change in prescription due to a medical condition” (NMAC, 2010). Polycarbonate lenses are covered. New lenses covered for diopter changes to plus or minus 0.75 or with the diagnosis of certain medical conditions; if the lenses cannot fit into the existing frames, frames will be replaced as well. | Limited to one routine vision exam every 36 months. One frame and set of corrective lenses covered every 36 months; “more frequently when an ophthalmologist or optometrist recommends a change in prescription due to a medical condition” (NMAC, 2010). Polycarbonate lenses covered for recipients with certain medical conditions, “with monocular vision . . . [or with] high-activity physical jobs” (NMAC, 2010). New lenses covered for diopter changes to plus or minus 0.75 or with the diagnosis of certain medical conditions. Contact lenses covered with prior authorization. Lost or broken eyeglasses covered with documentation on the recipient’s visual examination record (NMAC, 2010). Medicaid expansion recipients are not covered for eye exams to correct refract error or eyeglasses. Eye exams only |
Visit copay ranges from $0 to $7 (Kaiser Family Foundation, 2012b). |
| Contact lenses covered with prior authorization (NMAC, 2010). Lost or broken eyeglasses covered with documentation on the recipient’s visual examination record (NMAC, 2010). | covered to detect a disease of the eye or when part of a wellness exam. Eyeglasses only covered following cataracts removal surgery. | |||
| New Yorkx | Adults with incomes up to 138% poverty level. Pregnant women and infants to age 1 with income up to 223% of poverty level. Separate CHIP is available in New York for all children with income up to 400% of poverty level (Norris, 2015m). | “Polycarbonate lenses covered if needed for safety reasons; medical documentation is not necessary in this case” (New York State Medicaid Program, 2013, p. 10). | Optometric eye exam covered every 2 years, Covered more often if medically necessary. Glasses are covered when the initial correction or change in correction is at least .50 diopter (New York State Medicaid Program, 2013). Eyeglass lenses may be changed more frequently than every 2 years when medically necessary. Contact lenses covered when medically necessary. Orthoptic training may be covered with prior authorization (New York State Medicaid Program, 2013). “The maximum time period for which approval of a treatment plan will be granted is 6 months. At the end of the 6 month approved period, it is necessary to reapply for prior approval and supply information that details the progress made, the anticipated treatment plan, and the prognosis” (New York State Medicaid Program, 2013, p. 13). | None (New York State Medicaid Program, 2013). |
| North Carolina | “The aged, blind, and disabled. Also, parents with dependent children are eligible for Medicaid with a household income up to 45 percent of poverty level, and children are eligible for Medicaid or CHIP with incomes up to 211% of poverty; maternity-related coverage is available for pregnant women with incomes up to 196% of poverty” (Norris, 2015n). | Eligible for routine eye exams once per year. Eligible for eyeglasses once per year with prior approval. Eligible for contact lenses if medically necessary with prior approval (NC DMA, 2015b). | Routine eye exams and eyeglasses are not covered for adults (Kaiser Family Foundation, 2012a; NC DMA, 2015a). Pregnant women can request an eye exam if medically necessary due to complications of pregnancy (NC DMA, 2015b). “General ophthalmological services are covered for . . . patients when the level of service includes several routine optometric/ophthalmologic examination techniques that are integrated with the diagnostic evaluation” and are deemed medically necessary, and “not in excess of the beneficiary’s needs” (NC DMA, 2015a, p. 3). |
$3/visit (Kaiser Family Foundation, 2012b). |
| North Dakotay | “The aged, blind, and disabled as well as all adults are eligible with household incomes up to 133% of poverty, and pregnant women with incomes up to 147% of poverty. Children are eligible for Medicaid or CHIP with household incomes up to 170% of poverty (Norris, 2015o). | Covers one eye exam and refraction every 365 days for beneficiaries under age 20 (NDDHS, 2011). Exceptions made when medically necessary. Eye glasses covered once every 365 days (NDDHS, 2011). More often if medically necessary with prior | Covers one eye exam and refraction every 2 years. Exceptions made when medically necessary, or for adult diabetic clients (NDDHS, 2011). Eyeglasses covered once every 2 years. More often if medically necessary with prior authorization. Photochromic, certain tints, UV, slab-off, and Fresnel prism lenses covered if medically necessary with prior authorization (NDDHS, 2011). Some hard contact lenses covered for the correction of certain conditions. Replacement lenses and frames covered after 24 months (NDDHS, 2010). “An exception to the replacement limitation may be made | $2/visit (Kaiser Family Foundation, 2012b). |
| authorization. Photochromic, tinted, UV, slab-off, and Fresnel prism lenses covered if medically necessary with prior authorization (NDDHS, 2011). Replacement lenses and frames covered within the 12-month warranty with prior authorization. Contact lenses provided when medically necessary (NDDHS, 2011). | if new eyeglasses are required for a significant change in correction and the eyeglasses are prior approved” (NDDHS, 2010). | |||
| Ohio | “Adults are eligible with incomes up to 133% of FPL. Children are eligible with incomes up to 206% of FPL, and pregnant women are eligible with incomes up to 200% of FPL” (Norris, 2015p). | “One exam and pair of eyeglasses covered every 12 months (individuals younger than age 21)” (ODM, n.d.). | Adults ages 60 and older are eligible for “one eye exam and one pair or eyeglasses every 12 months” (ODM, n.d.). Adults between 21 and 59 are eligible for “one eye exam and one pair of eyeglasses every 24 months” (ODM, n.d.). Glaucoma screenings covered. Contact lenses covered with prior authorization. Medical and surgical services covered when medically necessary (ODM, n.d.). | $2/refractive exam and $1/for dispensing eyeglasses (ODM, n.d.). |
| Oklahoma | The aged, blind, and disabled are eligible. “Children under age 19 with income up to 210% of the poverty level, parents with income up to 46% of poverty, pregnant women with income up to 185% of the poverty level . . . includes pregnant women related to CHIP (134–185%).”z “Insure Oklahoma helps cover the | “Payment will be made for children with lenses, frames, low vision aids and certain tints when medically necessary including to protect children with monocular vision. Coverage includes one set of lenses and frames per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary” (OHCA, 2015). | Coverage for medical services necessary for the diagnosis and treatment of illness or injury (OHCA, 2015). “There is no provision for routine eye exams, examinations for the purpose of prescribing glasses or visual aids, determination of refractive state, treatment of refractive errors, or purchase of lenses, frames, or visual aids” (OHCA, 2015). |
$4/visit (OHCA, 2014). |
| cost of private insurance for adults working for small employers, benefits for low income adults that are self-employed and adults receiving unemployment benefits.”z | “Eye examinations are covered when medically necessary. Determination of the refractive state is covered when medically necessary” (OHCA, 2015). | |||
| Oregonaa | “The aged, blind, and disabled. Also, coverage is available if household income does not exceed 133% of poverty (185% for pregnant women and infants). CHIP is available for children with household incomes up to 300% of poverty” (Norris, 2016h). | Eye exams and glasses covered. Contact lenses not covered (OHP, n.d.). | Eye exams covered for pregnant women. For nonpregnant adults eye exams covered for eye conditions “except for disorders of refraction and accommodation (e.g. nearsightedness, farsightedness, astigmatism). Diagnostic services are still covered” (OHP, n.d.). Glasses covered for pregnant adults and other adults when medically necessary due to conditions such as aphakia or after cataracts surgery. Contact lenses not covered (OHP, n.d.). | Beneficiary may be responsible for a $3 copay per visit (Kaiser Family Foundation, 2012b). |
| Pennsylvaniabb | “Adults with income up to 138 percent of FPL are eligible for Medicaid. Children in households with incomes up to 319% of FPL are eligible for Medicaid or CHIP” (Norris, 2015q). | Two frames and four lenses covered per calendar year. Additional eyeglasses or contact lenses may be approved if medically necessary. | Two vision exams covered per calendar year. With fee-for-service, eyeglasses or contact lenses covered only with a diagnosis of aphakia. Eyeglasses may be covered without diagnoses for adults enrolled in a managed care plan. | $0.65–$3.80/service for glasses or visit (Kaiser Family Foundation, 2012a,b). |
| Rhode Islandcc | “The aged, blind, and disabled. Also, adults with income up to 133% of poverty, pregnant women | Covered as medically necessary with no other limits (State of Rhode Island, 2016). | Eye exams, eyeglasses (lenses, frames, and dispensing fee) and contact lenses (with prior authorization) covered once every 24 months for beneficiaries ages 21 and older | None (State of Rhode Island, 2016). |
| with income up to 253% of poverty, and children with incomes up to 261% of poverty” (Norris, 2015r). | (State of Rhode Island, 2016). Office visits covered for diagnosis and treatment when medically necessary. “The RI Medicaid program does not pay for a spare pair of eyeglasses; information provided over the telephone; cancelled office visits or appointments not kept; lost or stolen frames or lenses. The Medicaid program will not pay for any procedures or services that are unproved, experimental or research in nature. Services which are not medically necessary to treat the patient’s condition, or are not directly related to the patient’s diagnosis, symptoms or medical history are not reimbursable” (State of Rhode Island, 2016). | |||
| South Carolinadd | “The aged, blind, and disabled. Also children with household incomes up to 208% of FPL; working parents with dependent children with household incomes up to 89% of FPL; jobless parents with dependent children with household incomes up to 50% of FPL; pregnant women with household incomes up to 194% of FPL” (Norris, 2015s). | One comprehensive eye exam and one complete set of glasses covered once a year (South Carolina Health Connections, 2016). All lenses must be polycarbonate. Repairs covered as necessary. Replacements covered once per year. Contact lenses covered when medically necessary (South Carolina Health Connections, 2016). Orthotic and pleoptic | “Routine vision services for beneficiaries 21 and over are non-covered services. Routine vision services are defined as services related to refractive care: routine eye exams, refractions, corrective lenses, and glasses. Services related to disease of the eye are covered for an example glaucoma, conjunctivitis and cataracts” (South Carolina Health Connections, 2016, p. 2-198). “Adults can get an eye exam every year and a pair of glasses following cataract surgery” (South Carolina Healthy Connections, 2008, p. 15). | $3.30 per optometrist visit for adults over age 21 (South Carolina Healthy Connections, 2015). |
| training not covered (South Carolina Healthy Connections, 2016). | ||||
| South Dakota | “Pregnant women with household incomes up to 133% of FPL; children with household incomes up to 204% of FPL (for CHIP); parents with dependent children are eligible with incomes up to 58% of FPL” (Norris, 2015t). | Medicaid will pay for vision examinations; “annual examinations must be 12 months apart after age three” (SD DSS, 2015, p. 3). | “Covers exam, glasses and frames. Contact lenses are covered only when necessary for the correction of certain conditions. Replacement eyeglasses covered if 15 months have passed and a lens change is medically necessary” (SD DSS, 2015, p. 19). Optometrists and opticians may be seen without a referral; ophthalmology appointments require a referral (SD DSS, 2015). | “$2 for each procedure, lens, frame, exam, and repair service” (SD DSS, 2015, p. 14). |
| Tennesseeee | Parents with dependent children are eligible for Medicaid coverage with household incomes up to 103% of poverty (Brooks et al., 2015). “Children are eligible for Medicaid or CHIP with household incomes up to 250% of poverty, and pregnant women are eligible with incomes up to 195% of poverty” (Norris, 2015u). | “[For beneficiaries] under age 21: Preventive, diagnostic, and treatment services (including eyeglasses) [are] covered” (TennCare, 2014, p. 19). | “Vision services are limited to medical evaluation and management of abnormal conditions and disorders of the eye. The first pair of cataract glasses or contact lens/lenses following cataract surgery are covered” (TennCare, 2015, p. 5). | |
| Texasff | “The aged, blind, and disabled. Also, parents with dependent children are eligible with household incomes up to 15% of FPL. Children are eligible for | Children’s Medicaid covers eye exams and eyeglasses (Texas HHSC, 2014). | “One examination of the eyes by refraction may be provided to each eligible recipient every 24 months. This limit does not apply to diagnostic or other treatment of the eye for medical conditions” (Texas Medicaid, 2015). |
| Medicaid or CHIP with household incomes up to 201% of FPL, and pregnant women are eligible with household incomes up to 198% of FPL” (Norris, 2015v). | “Non-prosthetic eyewear includes contact lenses and eyeglasses (lenses and frames) [and] . . . is a benefit when the eyewear is medically necessary to correct defects in vision. This eyewear is covered once every 24 months unless the recipient experiences a visual acuity change measured in diopters or axis changes. . . . Contact lenses require prior authorization by the commission or its designee. . . . Prior authorization decisions are based on the provider’s written documentation supporting the need for contact lenses as the only means of correcting the vision defect” (Texas Medicaid, 2015). Replacement eyewear is not covered (Texas Medicaid, 2015). | |||
| Utahgg | “Coverage is available for pregnant women with incomes up to 139% of poverty, children with incomes up to 200% of poverty, and parents with incomes up to 51% of poverty. Utah’s guidelines also provide for other groups to obtain coverage depending on circumstances” (Norris, 2015w). | “Eyeglasses services, including lenses and frames” are covered by Utah Medicaid under EPSDT (Utah Department of Health, 2015, p. 2). | Medicaid covers one eye exam each year. Additional eye exams can be done when medically necessary (Utah Department of Health, | No copay for the annual eye exam if done by optometrist. $3 copayment for visits to the ophthalmologist (Utah Department of Health, 2016). |
| 2015). Corrective lenses and frames covered once every 2 years when medically necessary (e.g., changes in prescription). Damaged lens or frame repair covered as long as not due to member neglect or abuse once every 12 months (Utah Department of Health, 2015). Replacement glasses covered with change of 0.75 in diopter or when disease or damage to eye makes it medically necessary (Utah Department of Health, 2015). Contact lenses covered when medically necessary (Utah Department of Health, 2015). | ||||
| Vermonthh | Adults with incomes up to 133% of FPL are eligible for Medicaid. Children with household incomes up to 312% of FPL, and pregnant women with incomes up to 208% of FPL (CMS, 2014). | “One comprehensive eye exam and one intermediate eye exam are covered within the 24 month limit or more than two intermediate eye exams within a 2 year period” (DVHA, 2016a, p. 2). Beneficiaries under the age of 6 are allowed one new pair of eyeglasses every year, when medically necessary, whereas beneficiaries ages 6 and older and under 21 are eligible for new glasses every 2 years without prior approval (DVHA, 2012). Lenses are polycarbonate (DVHA, 2015). Replacement glasses covered within a 24-month period, and certain special lenses covered with prior authorization (DVHA, 2016a). | “Refraction and eye exams [are covered] when provided by an enrolled ophthalmologist or optometrist. Routine eye exams with the following limitations: one comprehensive eye exam and one intermediate eye exam are covered within a 2-year period, or two intermediate eye exams within a 2-year period. Diagnostic testing [is covered]. Non-eyewear aids to vision (such as closed circuit television) when the beneficiary is legally blind and when providing the aid to vision will foster independence by improving at least one activity of daily living” are covered with prior authorization (DVHA, 2012, p. 102). Eyeglasses, lenses, and contact lenses are not covered (DVHA, 2016a). | No copay for members under 21 (DVHA, 2016b). |
| Virginiaii | “The aged, blind, and disabled. Also, parents with dependent children | Eyeglasses and their repair are covered. Tinted lenses covered when medically | Eye examinations are covered once every 2 years. More frequent eye exams covered if medically necessary. Repair of frames | $1 copay for beneficiaries over age 21 for |
| are eligible with household incomes up to 49% of FPL. . . . Children are eligible for Medicaid or CHIP with household incomes up to 200% of FPL” (Healthinsurance.org, 2015b). Pregnant women are eligible with household incomes up to 200% of FPL for FAMIS MOMS (Cover Virginia, n.d.). | justified. Contact lenses not covered unless medically necessary. Eye exercises covered when medically necessary. Written documentation of need required after six sessions of orthoptic trainings (DMAS, 2012). | limited to once every 12 months. Repairs covered more often if medically justified (DMAS, 2012). | eye examinations and non-emergency vision analysis (DMAS, 2012). | |
| Washingtonjj | The aged, blind, and disabled. Also, adults with incomes up to 133% of FPL; children with household incomes up to 210% of FPL are eligible for no-premium Medicaid; children with household incomes 260% to 312% of FPL eligible (with premium); pregnant women with incomes up to 193% of FPL (Washington Apple Health, 2016c). | Vision hardware is covered for beneficiaries under age 20, including, vision therapy, eyeglasses (frames, lenses, and repairs) with a minimum prescription required, contact lenses (and backup glasses every 2 years), and replacement lenses with minimum required refractive change (Washington Apple Health, 2016b). Eye exam covered for asymptomatic clients once every 12 months (Washington Apple Health, 2016a). | Eye exams covered for asymptomatic clients once every 24 months (Washington Apple Health, 2016a). Orthotics, vision therapy, cataract surgery, strabismus surgery, blepharoplasty surgery, and implantable miniature telescope are covered services (Washington Apple Health, 2016a). |
| West Virginiakk | “The aged, blind, and disabled. Also, adults with incomes up to 138% of FPL; children with household incomes up to 300% of FPL are eligible for CHIP; pregnant women with incomes up to 158% of FPL” (Norris, 2016i). | Exams to prescribe eyeglasses or contact lenses including fitting, adjusting, or replacement are covered (West Virginia BMS, 2015). Frames are covered, as are replacements when the frames cannot be used or repaired. Contacts covered when medically necessary for a given condition. Orthoptics/pleoptic training is covered for children under age 10 when medically necessary (West Virginia BMS, 2015). | One comprehensive eye exam is covered per calendar year with prior authorization from utilization management vendor for medical necessity (West Virginia BMS, 2015). Addition diagnostic evaluations may be reimbursed if there is a documented, justifiable need. Glasses coverage is limited to beneficiaries post-cataract operation (within 60 days of surgery) (West Virginia BMS, 2015). Repair/replacement glasses not covered. Contact lenses covered with diagnosis of keratoconus or aphakia (West Virginia BMS, 2015). | None |
| Wisconsinll | “The aged, blind, and disabled. Also, children and pregnant women with incomes up to 300% of poverty; other adults with incomes up to 100% of poverty” (Norris, 2014b). | Coverage same as for adults. | One comprehensive ophthalmologic exam covered once per year (ForwardHealth, 2016). One low vision exam is covered once per year with prior authorization (ForwardHealth, 2016). Cataract surgery covered when medically necessary. Contact lenses covered with prior authorization if medically necessary. Contact lenses covered without prior authorization with diagnosis of aphakia or keratoconus. Contact lens replacements covered once per year. Eyeglasses covered once per year. Minor repairs covered. Replacements for lost or damaged glasses covered once per year. Any addition replacements require prior approval (ForwardHealth, 2016). | $0.50–$3 for glasses or exams, depending on the specific service (Kaiser Family Foundation, 2012a,b). |
| Wyomingmm | “Pregnant women and children are eligible with household incomes up to 154% of poverty (children are eligible for CHIP with household incomes up to 200% of poverty). Parents with dependent children are eligible with household incomes up to 56% of poverty” (Norris, 2015x). | “Comprehensive services including eyeglasses for clients under the age of 21, with limits, covered when provided by an ophthalmologist, optometrist or optician” once per year (Wyoming Department of Health, 2011, p. 15). Eye exams covered when medically necessary to determine visual acuity or treat eye disease or injury. Replacement of lenses and frames allowed once. Contact lenses covered if medically necessary with prior authorization. Vision therapy covered without prior authorization. (Wyoming Department of Health, 2016). | Glasses and contact lenses not covered (Wyoming Department of Health, 2011). Eye exams are only covered for the treatment of eye disease or eye injury. Medical treatment is covered for beneficiaries who are either at risk for eye disease due to chronic illness or otherwise, or with eye injuries (Wyoming Department of Health, n.d.). |
None. |
NOTE: Footnotes indicate that a state representative has verified the accuracy of the information.
a For Medicaid benefits in general, includes the 5 percent federal poverty level disregard, unless otherwise excluded by the state representative.
b Many states require a pharmacy copay (not enumerated here), which presumably would apply to prescription eye medications including various drops. Individual prescription copay are not always listed for each state but are typically <$3. Copays in general often do not apply for beneficiaries under age 18 (or, sometimes, 21), pregnant women, or patients in long-term care programs/nursing facility residents.
c Personal communication, R. Rawls, Alabama Medicaid Agency, May 24, 2016.
d Personal communication, S. Dunkin, Alaska Division of Health Care Services, March 23, 2016.
e Personal communication, L. Raymond, Arizona Health Care Cost Containment System, May 10, 2016.
f Personal communication, H. Hendrix, Jr., California Department of Health Care Services, May 24, 2016.
g Personal communication, E. Freudenthal, Colorado Department of Health Care Policy & Financing, May 10, 2016.
h Personal communication, E. Atwerebour, Connecticut Division of Health Services—Medical Policy, April 5, 2016.
i Personal communication, K. Mahoney, Delaware Division of Medicaid and Medical Assistance, May 8, 2016.
j Personal communication, C. Bishop, District of Columbia Department of Health Care Finance, May 11, 2016.
k Personal communication, A. Russell, Georgia Department of Community Health, May 19, 2016.
l Personal communication, C. Toma, Hawaii Medicaid, March 28, 2016.
m Personal communication, M. Cook, Indiana Family and Social Services Administration, March 29, 2016.
n Personal communication, A. L. McCoy, Iowa Department of Human Services, May 31, 2016.
o Personal communication, S. Robinson, Kentucky Cabinet for Health Services, May 9, 2016.
p Personal communication, L. Gonzales, Louisiana Department of Health and Hospitals, April 20, 2016.
q Personal communication, M. Lehner, Maryland Acute Care Administration, May 13, 2016.
r Personal communication, E. Emerson, Michigan Department of Health and Human Services, May 10, 2016.
s Personal communication, D. Preshinger, Montana Department of Public Health & Human Services, April 11, 2016.
t Personal communication, J. Swenson, Nebraska Department of Health & Human Services, May 12, 2016.
u Personal communication, J. Osalvo, Nevada Division of Health Care Financing and Policy, May 9, 2016.
v Personal communication, D. Peterson, New Hampshire Department of Health and Human Services, June 1, 2016.
w Personal communication, K. Armijo, New Mexico Human Services Department, May 13, 2016.
x Personal communication, M. J. O’Brien, New York State Department of Health, May 13, 2016.
y Personal communication, T. Solberg, North Dakota Department of Human Services, May 10, 2016.
z Personal communication, M. Triplet, The Oklahoma Health Care Authority, May 13, 2016.
aa Personal communication, A. Robbins, Oregon Health Authority, May 24, 2016.
bb Personal communication, R. V. Foster, Pennsylvania Department of Human Services, May 20, 2016.
cc Personal communication, S. O’Connell, Rhode Island Executive Office of Health & Human Services, March 25, 2016.
dd Personal communication, V. Williams, South Carolina Health Connections, May 20, 2016.
ee Personal communication, A. Butler, Division of Health Care Finance & Administration, March 23, 2016.
ff Personal communication, J. Seyller, Texas Health & Human Services, March 28, 2016.
gg Personal communication, K. Young, Utah Department of Health, May 31, 2016.
hh Personal communication, D. Fuoco, Vermont Agency of Human Services, May 27, 2016.
ii Personal communication, B. McCormick, Virginia Department of Medical Assistance Services, May 11, 2016.
jj Personal communication, A. McKoy, Washington Health Care Authority, March 28, 2016.
kk Personal communication, R. D. Ernest Jr., West Virginia Bureau for Medical Services, May 11, 2016.
ll Personal Communication, S. Thomas, Wisconsin Department of Health Services, May 25, 2016.
mm Personal Communication, A. Burton, Wyoming Medicaid, May 17, 2016.
REFERENCES
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