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

Your Colorado optometrist can participate in Medicaid and provide eye exams and glasses for your children at no cost to you. Nearly 1 in 4 children in Colorado is insured through Medicaid. Because so many children are covered by Medicaid, there are six points you need to understand.

1. Medicaid coverage for vision varies from state to state, so don’t assume you’ll have the same benefits when you move to Colorado from another state. There are different types of vision care coverage for children and adults. There have been changes to vision care benefits in recent years and they will continue to change with health care reform. Expansion or reduction of benefits may occur at any time. Medicaid is a state program administered in conjunction with the Federal Government. States may vary coverage policies to some extent. The state of Colorado has its own plan. An example of the differences is coverage for adults. Adults have a $2.00 copay for eye exams and limited benefits for eyeglasses. Many states have full coverage for adults.
2. For Medicaid vision coverage in Colorado, children’s vision insurance coverage is defined as age 20 or younger. When you turn 21, Colorado Medicaid considers you an adult and benefits change. Children are eligible for an eye exam by their optometrist as needed with no copay.
3. Contact lens fitting fees incur additional charges on top of the regular eye exam. These are not covered unless there is an eye disease that deforms the cornea. Contact lenses may be the only way to provide acceptable visual acuity. Actual contact lenses are also not covered unless there is an applicable medical diagnosis. This is not an area where a patient can plead her case. If there are specific medical conditions that require contact lenses, your ophthalmologist must submit a form for your case to be considered. The review process can take from several weeks to several months. Usually approved if contact lenses are the only way to correct your vision due to corneal eye disease. Your optometrist may need to submit a prior authorization form more than once to communicate the need for special consideration, so please be patient.
4. One standard eyeglass frame and lenses are covered with no copay. A standard frame means frames are limited to inexpensive frames. That doesn’t mean they’re necessarily low quality. Your optometrist is only allowed limited reimbursement for the eyeglass frame. Repairs to 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 their glasses. Loss of eyeglasses is not specifically defined as a benefit, but may be covered.
5. Lens treatments such as scratch-resistant coatings, anti-glare coatings, tints, and thin lens materials are not covered. Scratch resistant coatings are the only option you should buy. Prescription eyeglass lenses without a scratch coating are very likely to have scratch marks within a day or two of teen wear. Scratch resistant coatings are not scratch proof, but they will certainly extend the life of the lenses. There is a way to cover thinner, lighter lenses for your child. If you order polycarbonate lenses, they will be much thinner and more attractive for higher eyeglass lens prescriptions and help your child’s self-image. Polycarbonate lenses are generally recommended for children and teens who need glasses due to their extreme impact resistance.
6. Other services may be available with prior authorization. Vision devices are sometimes approved for children who have significant vision loss due to eye disease, some lens treatments, lazy eye therapy, and other services. Don’t expect a quick approval, but it’s worth the wait when the covered service ends.

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