Does MassHealth Cover Eye Exams? Glasses, Contacts, and Medicare

Yes, MassHealth does cover eye exams if you are enrolled in Standard, CommonHealth, CarePlus, or Family Assistance. Members under 21 can get a comprehensive eye exam once every 12 months, and members 21 and older can get one every 24 months.¹ There are no copays for covered vision services as of April 2024, and most members do not need a referral for a routine exam.² Coverage goes beyond the exam itself to include eyeglasses, repairs, and contact lenses when they are medically necessary.

Which MassHealth Plans Include Vision Coverage

Four coverage types carry the full vision benefit, and the benefit is identical across them: Standard, CommonHealth, CarePlus, and Family Assistance.³ If you are on one of these plans, you get exams, eyeglasses, frames, lens repairs and replacements, tinted lenses when medically justified, and contact lenses when medically necessary.

Several other MassHealth programs work differently, and this is where people get caught:

MassHealth Limited covers emergency medical conditions only. Routine vision care is not included. If you also qualify for the Health Safety Net, you may receive vision services, but only at a participating acute care hospital or community health center.⁴
The Children’s Medical Security Plan covers annual and medically necessary eye exams but will not pay for eyeglasses or other ophthalmic materials.¹
The Medicare Savings Program does not include vision care at all. It only pays Medicare premiums, copays, and deductibles.³
One Care, Senior Care Options, and PACE members fall outside the standard rules. Contact your plan directly to find out what your vision benefit looks like.¹

When You Can Get an Exam Sooner

The 12-month and 24-month limits are the default, not a hard cap. You can be seen more often if your physician refers you or if you have a documented medical condition that justifies closer monitoring.¹ Qualifying conditions listed in the regulations include cataracts, glaucoma, blurred or double vision, eye pain or infection, diabetes, HIV, hyperthyroidism, and the use of long-term medications known to cause ocular side effects.⁵

Children and young adults have a stronger protection. Under the federal Early and Periodic Screening, Diagnostic, and Treatment benefit, MassHealth must cover all medically necessary vision services for members under 21, even where the service would exceed what an adult could receive.⁶

Eyeglasses, Lenses, and What Isn’t Included

MassHealth pays for one new pair of eyeglasses every 12 months for members under 21 and every 24 months for adults. There is no dollar cap, but you have to choose your frames from the MassCor Vision Catalog, which organizes frames into adult plastic, adult metal, youth plastic, and youth metal collections.⁷ Your eye care provider will have the catalog in the office.

Standard lenses come in single-vision or bifocal, in CR39 plastic or polycarbonate. Progressive, no-line bifocals are not covered. The exclusion is spelled out at 130 CMR 402.435(A)(6).⁸ If you genuinely cannot tolerate a lined bifocal, your provider can document a qualifying reason, such as physical disability, advanced age, or inability to adjust, and MassHealth will instead pay for two separate single-vision pairs, one for distance and one for reading.¹

Pink 1 and Pink 2 tinted lenses are covered if you have a pathological condition or a documented history of wearing them. Other tint colors need prior authorization, must be on plastic lenses, and require documented medical necessity. Tints prescribed only for photophobia are not covered.¹

Broken, Lost, or Spare Glasses

MassHealth will repair broken glasses and replace lost ones, with limits. For adults, any repair within 24 months of the original dispensing date needs prior authorization. One replacement for lost glasses is allowed within your normal frequency window (12 months under 21, 24 months at 21 and older) without prior authorization; additional replacements inside that window need approval.⁵ Repairs have to be done by the optician who dispensed the original pair.

A second, spare pair is available with prior authorization if you have aphakia, myopia or hyperopia greater than 7.00 diopters, or astigmatism greater than 3.00 diopters.¹

Contact Lenses

Contact lenses are covered only when medically necessary, and the list of qualifying conditions is narrow: postoperative cataract extraction, keratoconus, anisometropia greater than 3.00 diopters, or myopia or hyperopia greater than 7.00 diopters.¹ Contacts chosen for cosmetic reasons or convenience are not covered. If you meet the medical criteria, no prior authorization is needed.

Services That Require Prior Authorization

Several things beyond a routine exam and basic glasses have to be approved by MassHealth before they will be paid for:

Low-vision aids such as magnifiers.⁹
High-index lenses for very strong prescriptions.
Polycarbonate lenses for adults. Children under 21 do not need prior approval, and adults who are amblyopic or monocular are also exempt.
Vision training.
Special-needs glasses and any service not otherwise listed.

Approval confirms medical necessity. It does not override other requirements such as your being eligible on the date of service.

Referrals, Networks, and Finding a Provider

How you get to an eye doctor depends on how your MassHealth coverage is delivered. If you are enrolled in a managed care organization or an accountable care partnership plan, the exam itself is covered by your health plan and must be done by a provider in that plan’s network. The glasses, visual aids, and other materials are still billed directly to MassHealth and can come from any MassHealth provider.¹

If you are in a Primary Care ACO or the Primary Care Clinician Plan, the exam is covered directly by MassHealth, but you need a referral from your primary care provider first. The referral can be waived if the eye doctor is inside the ACO’s Referral Circle.¹⁰

Fee-for-service members can search the online MassHealth Provider Directory and filter by ophthalmology or optometry.¹¹ If you are in an MCO or ACPP, call your health plan for its in-network list. MassHealth Customer Service answers general questions at (800) 841-2900 (TDD/TTY: 711), Monday through Friday, 8 a.m. to 5 p.m.¹

If You Also Have Medicare

Members with both Medicare and MassHealth are covered under coordination-of-benefits rules. Medicare pays first, and MassHealth picks up copays, deductibles, and other out-of-pocket costs, but only when the provider participates in both networks.¹ Traditional Medicare has very limited routine vision coverage, so this coordination matters most for medically necessary eye care, such as monitoring diabetic eye disease, rather than for a routine exam and glasses.

1
Mass.gov. Learn About MassHealth Vision Care Services
2
WellSense. MassHealth MCO Standard Covered Services List
3
Mass.gov. Chart of MassHealth Covered Services
4
Mass.gov. MassHealth Limited and Health Safety Net
5
Mass.gov. Revisions to Vision Care Regulations and HCPCS Codes
6
Mass.gov. MassHealth EPSDT Benefit
7
MassCor Industries. MassHealth Vision Care Catalog
8
Cornell Law Institute. 130 CMR 402.435 – Service Exclusions
9
Cornell Law Institute. 130 CMR 402.408 – Prior Authorization
10
Mass.gov. MassHealth Authorizations and Referrals
11
Mass.gov. MassHealth Provider Directory