Colorado Medicaid Vision Care Benefits – 6 Things You Need to Know About Your Eyecare

July 20, 2017

Your Colorado optometrist may participate in Medicaid and provide eye exams and glasses for your children at no cost to you. Almost 1 of every 4 children in Colorado is insured through Medicaid. Because so many children are covered under Medicaid there are six points you need to understand.

  1. Medicaid coverage for vision varies state by state so don’t presume you will have the same benefits when moving to Colorado from another state. There are different types of vision care coverage for children and adults. Changes in eye care benefits have occurred in the last few years, and will continue to change with health care reform. Expansion or cut backs in benefits may occur at any time. Medicaid is a state run program run in cunjunction with the Federal Governement. States can vary the coverage policies to some degree. The state of Colorado has it’s own plan. One example of the differences is adult coverage. Adults have a $2.00 co-pay for eye exams and limited benfits for eyeglasses. Many states have full coverage for adults.
  2. For Medicaid vision coverage in Colorado, children’s vision insurance coverage is defined by age 20 and under. When reaching age 21, Colorado Medicaid considers you an adult and the benefits change. Children are eligible for an eye exam by their optometrist as needed with no co-pay.
  3. Contact lens fitting fees entail additional charges above the regular eye examination. These are not covered unless there is an eye disease that warps the cornea. Contact lenses may be the only way to provide acceptable visual acuity. The actual contact lenses are also not covered unless their is an applicable medical diagnosis. This is not a area where a patient can plead their case. If there are specific medical conditions requiring contact lenses your eye doctor has to file a form to have your case considered. The review process can take several weeks to several months. It is normally approved if contact lenses are the only way to correct your vision due to a corneal eye disease. Your optometrist may have to submit a form for prior authorization more than once to communicate the need for special consideration, so you will need to have some patience.
  4. A standard eyeglass frame and lenses are covered with no co pay. A standard frame means frames are limited to inexpensive frames. That does not mean they are necessarily low quality. Your optometrist is only allowed a limited reimbursement for the eyeglass frame. Repairs for broken frames or lenses are a benefit, and a replacement frame is provided if the frame cannot be repaired. While this is not necessarily an unlimited benefit, it can be used more than once if your child is prone to breaking glasses. Loss of eyeglasses is not specifically defined as a benefit but may be covered.
  5. Lens treatments such as scratch resistant coatings, glare free coatings, tints, and thin lens materials are not covered. Scratch resistant coatings are the one option you should purchase. Prescription eye glass lenses without a scratch coating will most likely have scratch marks on them within a day or two of teenager usage. Scratch resistant coatings are not scratch proof, but they will certainly extend the usable life of the lenses. There is a way to have thinner, lighter lenses covered for your child. If you request polycarbonate lenses, they will be much thinner and attractive for higher eye glass lens prescriptions, and help your child’s self image. Polycarbonate lenses are usually recommended for children and teens needing eyeglasses due to their extreme impact resistance.
  6. Other services may be available with prior authorization. Vision devices for children that have significant sight loss from eye diseases, some lens treatments, therapy for lazy eye, and other services are sometimes approved. Don’t expect a fast approval, but it is worth the wait when the service ends up being covered.

Medicaid is constantly changing and this information is provided as educational, not as representative of current state policy. Different types of programs are available in some areas of Colorado. Eligibility for enrolling in Medicaid and understanding your vision benefits is your responsibility, and the State of Colorado has resources to help you. Visit the Colorado State website at: www.colorado.gov/hcpf [http://www.colorado.gov/hcpf]. Thousands of children are eligible for Medicaid coverage in Colorado but are currently not enrolled or covered by any insurance plan. You can help keep your kids healthy by taking the time to enroll them now, and keeping up with annual preventative eye doctor examinations.

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