Does Medi-Cal Cover Glasses for Adults?

Medi-Cal, California’s Medicaid program, provides healthcare services to low-income individuals and families across the state. Many wonder if this program extends its coverage to vision services for adults, particularly eyeglasses. Understanding Medi-Cal’s vision benefits is important for eligible individuals. This article clarifies Medi-Cal’s adult vision care coverage and the process for accessing these benefits.

Medi-Cal Vision Benefits for Adults

Medi-Cal covers vision benefits for eligible adults, including comprehensive eye examinations and eyeglasses. This coverage was reinstated for adults aged 21 and older, effective January 1, 2020, making vision care, including frames and lenses, available to a broader range of adult beneficiaries.

Eligibility for Adult Vision Coverage

To be eligible for Medi-Cal’s vision benefits, an adult must qualify for full-scope Medi-Cal coverage. Eligibility is determined based on income, household size, and other factors, with the program serving various low-income populations, including adults, families with children, and individuals with disabilities. Individuals can verify their Medi-Cal eligibility and the scope of their benefits by checking their Benefits Identification Card (BIC) or contacting their specific Medi-Cal managed care plan. County social services agencies also provide assistance in understanding eligibility and benefits.

Scope of Covered Services and Materials

Medi-Cal’s vision benefits for adults typically include a routine eye exam once every 24 months, which assesses eye health and determines eyeglass prescriptions. If corrective lenses are needed, the program covers standard eyeglasses, including frames and lenses. This usually encompasses single vision, bifocal, and trifocal lenses. The selection of frames is generally limited to a Medi-Cal approved inventory or within a specific allowance. New glasses are typically provided every 24 months, or sooner if there is a significant prescription change or if the glasses are lost or damaged.

Certain premium lens features, such as anti-reflective coatings or progressive lenses, are typically not covered unless deemed medically necessary and often require prior authorization. Similarly, contact lenses are generally excluded from routine coverage for adults, but they may be covered if medically necessary due to specific eye conditions where eyeglasses are not suitable. This requires prior authorization and applies to conditions such as aphakia, aniridia, or keratoconus. Artificial eye services and low vision testing for severe impairment are also covered benefits.

Steps to Obtain Glasses Through Medi-Cal

Obtaining glasses through Medi-Cal begins with locating an eye care professional who accepts Medi-Cal. Beneficiaries can typically find participating optometrists or ophthalmologists through their Medi-Cal managed care plan’s provider directory or by contacting the California Department of Health Care Services (DHCS). Some managed care plans partner with vision networks like Vision Service Plan (VSP) or March Vision Care, and their websites or customer service lines can help locate in-network providers. A referral from a primary care physician is generally not required for routine eye exams.

Once a provider is identified, the next step is to schedule a comprehensive eye exam. During this appointment, the eye care professional will evaluate eye health and determine the appropriate prescription for corrective lenses. If glasses are prescribed, the patient will typically select frames and lenses from the options covered by Medi-Cal, usually available directly at the provider’s office. The provider will then order the eyeglasses.

The timeline for receiving completed eyeglasses can vary, but patients are generally advised to inquire about the expected delivery time at the time of ordering. Upon receiving the glasses, it is advisable to ensure they fit properly and the vision correction is satisfactory. Should any issues arise with the glasses, such as discomfort or vision problems, patients should contact their eye care provider for adjustments or further evaluation.