Medicaid/Healthy Michigan Plan vision services

Medical policy

Medicaid vision services coverage

Vision therapy

Vision therapy (orthotic service) is covered for limited clinical conditions.

Routine eye exams

All routine vision is now covered by EyeMed as of Dec. 1, 2022. All claims must be submitted to EyeMed for routine services payment. All medical vision services are still covered by Priority Health.

Medicaid/Healthy Michigan Plan beneficiaries receive a routine vision exam once every 24 months and 1 day. With attestation of medical necessity, additional routine comprehensive eye exams may be covered for Medicaid/Healthy Michigan Plan members where less than 2 years have elapsed since the last examination.

Visit EyeMed for Priority Health Medicaid for more information.

New lenses and frames

A complete pair of eyeglasses is a Medicaid covered benefit and is covered every 24 months and 1 day at no out-of-pocket expense to the member with the exception of copayments for some members. Members must choose an ophthalmic frame from the Medicaid-covered frame collection. EyeMed considers standard lenses to be uncoated, CR-39 plastic single vision, bifocals (Round 22, FT 25, FT 35 and Executive) and trifocals (FT-7x28). Any other lens types and options are covered only when medically necessary.
Members may choose to pay out-of-pocket for a selection of non-Medicaid covered frames, lenses and lens options.

Members can choose from a selection of progressive lenses, anti-reflective treatments, tint, photochromic and other lens options as part of the buy-up. They will pay the amounts indicated on the Buy-Up Schedule.

Covered lenses include:

Standard single vision (uncoated, CR-39 plastic)
Standard bifocal (Round 22, FT 25, FT 35 and Executive )
Standard trifocals (FT-7x28)
Polycarbonate lenses

Medically necessary lenses and options include:

Photochromic, tinted/dyed lenses, UV protection, lens edge treatments, aspheric, mid-index, and high-index are covered only when medically necessary at the doctor’s discretion.
Medicaid covers 2 pairs of single vision eyeglasses (1 for near visual tasks and the other for distance visual tasks) when the below criteria are met:

When the beneficiary has clearly demonstrated the inability to adjust to bifocals after a reasonable trial period.
When the beneficiary’s physical condition does not allow bifocal usage

Repair of lenses and frames

Minor repairs resulting from typical wear patterns (e.g., aligning temples, insertion of screws, adjusting frames) are not a separately reimbursable service and cannot be billed. If the provider determines that eyeglasses are repairable, the provider must guarantee the repair for a minimum of 30 days. Subsequent repair for the same issue within 30 days is your responsibility.

Major eyeglass repairs (e.g., reinsertion of a lens, repair of a sheared screw, shortening or replacing temples, etc.) are covered and should be treated as a replacement pair.

Replacement lenses and frames

Beneficiaries are eligible for a complete replacement pair of eyewear if the original eyeglasses have been lost, stolen or broken beyond repair. If the beneficiary’s frames are broken beyond repair, treat it as a complete replacement pair of eyeglasses.

Beneficiaries are limited to the following replacement pairs:

For beneficiaries age 21 and over, 1 pair per year
For beneficiaries under age 21, 2 pairs per year
One year is defined as 365 days from the date the first pair of eyeglasses (initial or subsequent) was ordered.
Additional replacements may be available if medically necessary. Follow the process for ordering medically necessary eyewear to process those orders.

Medicaid covers the replacement of 1 or more corrective lens, without frames, in the event of damage or breakage, or with a 0.75 diopter change or greater.

Lenses being replaced because of damage must be an identical copy of the lens(es) being replaced.
Order the lens(es) directly from the lab.

Coverage exclusions

Special independent diagnostic tests or treatment procedures
Progressive lenses, except as buy-ups
Anti-reflective treatments
Oversized lenses and no-line lenses, except as buy-ups
All services or supplies that are not medically necessary
Experimental/investigational drugs, procedures, devices or equipment
Charges for missed appointments
Charges for time involved in completing necessary forms, claims or reports
Orthoptic or vision training, low vision aids and any associated supplemental testing
Aniseikonic lenses
Medical and/or surgical treatment of the eye, eyes or supporting structures
Services provided as a result of any workers’ compensation law
Plano lenses and plano sunglasses (non-prescription)
Services or materials provided by any other group benefit plan providing vision care
Services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the insured person are within 31 days of such an order
Not all materials are available at all provider locations
Members can’t combine benefits with any discount, promotional offer or other group benefits plans

Medicaid vision services billing

All claims for routine service claims must be sent to EyeMed for payment.

Visit EyeMed for Priority Health Medicaid for more information and resources including a provider manual, fee schedules, billing requirements, "how to" guides and more.

Access EyeMed's online claims system.

Medical vision service codes

See the Priority Health Vision Care medical policy above for details on codes and coverage.

Ophthalmologist/optometrist billing for cataract surgery & services

See Procedures & services > Medical/surgical > Cataract surgery for billing details.

Contact lens evaluation billing

Either an ophthalmologist or optometrist may bill 92310, contact lens evaluation. Benefit language states that this service is included in the contact lens limitation. If contact lens benefit has not been met, all or a portion of the 92310 could be paid. However, once the patient has met their benefit limit for the contacts, 92310 will be denied as member liability.

Bill 92310 only at the time of original contact lens prescription and fitting.
When the provider performs a contact lens evaluation over and above the standard eye exam, bill either an S0620 or S0621 (standard eye exam) and the 92310.

Contact lens evaluation billing, 92310

Either an ophthalmologist or optometrist may bill 92310, contact lens evaluation.

Benefit language states that this service is included in the contact lens limitation. If contact lens benefit has not been met, all or a portion of the 92310 could be paid. However, once the patient has met their benefit limit for the contacts, 92310 will be denied as member liability.

Bill 92310 only at the time of original contact lens prescription and fitting.
When the provider performs a contact lens evaluation over and above the standard eye exam, bill either an S0620 or S0621 (standard eye exam) and the 92310.