Medicaid Vision Benefit
What is the Colorado Medicaid Vision Services Benefit?
Vision services covered by Colorado Medicaid differ between children and adults. Please see the “Who is eligible” section for more information. If you are enrolled in a managed health care plan, you may have additional benefits not listed below.
Who is eligible?
- Children (age 20 and under): The Early Periodic Screening Diagnosis and Treatment (EPSDT) Program provides vision benefits such as standard eyeglasses, replacement or repair of frames or lenses, contact lenses (must be medically necessary and prior authorized unless provided for vision correction after surgery), ocular prosthetics (when prior authorized), and eye exams.
- Adults (age 21 and older): Medically necessary eye examinations, eyeglasses and contact lenses ONLY following eye surgery. Does not require prior authorization, and surgery may have been performed at any time during the patient’s life.
What services are available?
|AVAILABLE BENEFIT||BENEFIT LIMITATION||COST|
|Eye examinations - Adult||Only problem-focused visits are covered||$2 co-pay|
|Eye examinations - Child (birth to age 18)||No limitation||$0|
|Eye examinations - Child (19 to 20)||No limitation||$2 co-pay|
|Standard eye glasses - Adult||After eye surgery only, limited to single or multi-focal clear plastic lenses and one standard frame||$0|
|Standard eye glasses - Child||Limited to single or multi-focal clear plastic lenses and one standard frame||$0|
|Contact lenses||Only covered when there is a medical reason; requires prior authorization||$0|
Requires prior authorization
|Low vision aids||Requires prior authorization||$8|
- Contact lens supplies and contact lens insurance are not benefits.
- Extra options added on to standard frames and lenses can be purchased at cost to the client, but the provider must obtain written agreement from the client to pay for non-covered costs.
- Providers may not bill clients for separate charges for services.
How often can glasses be replaced or repaired?
- Repair of eyeglasses is covered only when due to broken frames or lenses.
- Replacement glasses shall be provided when medically necessary or when the glasses are damaged to the extent that repairs are not cost effective.