Does Medi-Cal Cover Contact Lenses?
Navigate Medi-Cal's eye care coverage. Discover under what conditions contact lenses are included and how to utilize your vision benefits.
Medi-Cal serves as California’s public health insurance program, providing free or low-cost healthcare to individuals and families with limited incomes. It ensures access to a range of medical services, including essential vision care, for all eligible residents.
Medi-Cal Vision Benefits
Medi-Cal provides vision care benefits to its eligible members. All beneficiaries are covered for a routine eye examination, available once every 24 months. This examination checks the overall health of the eyes and determines if a prescription for eyeglasses is necessary.
Eyeglasses, including both frames and lenses, are covered for specific Medi-Cal beneficiaries. This coverage is extended to individuals under 21 years of age and those residing in nursing homes. Medi-Cal also covers artificial eye prosthetics for individuals who have lost an eye due to injury or disease. Low vision testing is available for those with significant vision impairment not correctable by standard means, which interferes with daily activities.
Contact Lens Coverage
Contact lenses are not covered by Medi-Cal for cosmetic purposes or as a routine alternative to eyeglasses for standard vision correction. Coverage is limited to situations of medical necessity, meaning contact lenses must be the only medically appropriate method to correct vision or treat a specific eye condition.
Specific medical conditions that may warrant contact lens coverage include aphakia, a condition where the eye lacks a lens, and keratoconus, a progressive eye disease causing the cornea to thin and bulge into a cone shape. Severe anisometropia, where there is a significant difference in refractive error between the two eyes, can also qualify if eyeglasses are insufficient for adequate vision correction. For such specialized coverage, prior authorization is required from the Department of Health Care Services (DHCS) Vision Services Branch. Covered lenses are limited to those approved by the federal Food and Drug Administration (FDA).
Accessing Your Vision Benefits
To utilize Medi-Cal vision benefits, members begin by locating a participating vision provider. This can be done by contacting their Medi-Cal managed care health plan, as many plans partner with vision care networks. Alternatively, individuals can consult online provider directories or reach out to their county Medi-Cal office for assistance in finding an in-network provider. A referral from a primary care physician is not required for a routine eye examination.
Once a provider is identified, members can schedule a comprehensive eye exam. The eye care professional will assess eye health and determine any need for vision correction. If medically necessary contact lenses are prescribed, the provider will initiate the prior authorization process with DHCS. This involves submitting documentation, followed by fitting, ordering the lenses, and scheduling follow-up appointments.