Yes, Medicaid does cover vision care in Michigan, but what you get depends on your age and your managed care plan. Children under 21 receive the broadest benefits, including routine exams, glasses, and replacements. Adults 21 and older typically get one routine eye exam and one pair of glasses every 24 months through their managed care plan, with a $2 copay per vision visit.
What Adults Get
There is a wrinkle worth understanding up front. Under Michigan’s fee-for-service Medicaid policy, routine adult eye exams, refractions, and standard eyeglasses are not covered. A 2009 executive order eliminated that coverage, and Public Act 187 of 2010 added back only low-vision services and coverage for eye disease and injury.1Michigan.gov. Bulletin MSA 11-49 In practice, almost everyone on Michigan Medicaid is enrolled in one of nine managed care organizations, and those plans include routine vision benefits.
Through managed care, adult members can generally expect:
- One routine eye exam every 24 months.2Aetna Better Health of Michigan. Vision and Dental Benefits
- One pair of eyeglasses (frames and lenses) every 24 months.3Priority Health. Vision Care
- One replacement pair per year if glasses are lost, stolen, or broken beyond repair.4Upper Peninsula Health Plan. Eyecare and Eyewear Benefits
Some plans go further. UnitedHealthcare Community Plan members receive annual diabetic eye exams with a dilated retinal exam and annual glaucoma screenings for at-risk members, which includes people with diabetes, those with a family history of glaucoma, and African Americans age 50 and older.5March Vision Care. Michigan Provider Reference Guide That plan also covers medically necessary vision therapy, up to 12 visits per year.
What Children Get
Children on Michigan Medicaid have stronger vision benefits than adults, and that is required by federal law. The Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT) requires states to cover vision screenings at every well-child visit, plus eyeglasses and any needed diagnostic or treatment services for anyone under 21.6Medicaid.gov. Vision and Hearing Screening Services for Children and Adolescents States must also add screenings between regular checkups whenever a parent or provider suspects a problem.
In Michigan, that generally translates to routine eye exams every two years, one pair of glasses every two years, and up to two replacement pairs per year if glasses are lost, stolen, or broken.7Blue Cross Complete of Michigan. Core Benefits That replacement allowance is double what adults get. Annual glaucoma screenings and retinal exams for children with diabetes are also covered. Kids 20 and under can get polycarbonate lenses without prior authorization or a safety frame, a benefit added in 2012.1Michigan.gov. Bulletin MSA 11-49
Contact Lenses
Contacts are not covered as a routine alternative to glasses. They are a benefit only when medically necessary for specific conditions: aphakia (the absence of the eye’s natural lens, congenital or after surgery), keratoconus when glasses cannot correct vision to 20/40 or better, and anisometropia of 2.00 diopters or greater that produces a significant image-size difference between the eyes.8Michigan.gov. Bulletin MSA 13-04 Other conditions with no alternative treatment may also qualify.
When contacts are approved, adults are allowed two units per year, including replacements. Children under 21 can receive up to four replacement units per year.9March Vision Care. Michigan Vision Benefits The provider must document medical necessity in the patient’s record and must supply the lenses directly rather than have the member buy them separately.8Michigan.gov. Bulletin MSA 13-04
Medical Eye Care
Separate from routine vision benefits, Michigan Medicaid covers eye care that is medically necessary to diagnose or treat disease, injury, or an abnormal condition of the eye. This applies to both adults and children. Covered services include non-routine eye exams, evaluation and management, special ophthalmological testing, and glaucoma treatment.1Michigan.gov. Bulletin MSA 11-49 Diabetic retinopathy, cataracts, macular degeneration, strabismus, and amblyopia all fall under this category.10Priority Health. Medical Eye Care Policy
Low-vision services were reinstated for adults in 2010 and include low-vision evaluations, rehabilitative services, and aids like specialized glasses and contact lenses, provided a low-vision diagnosis code is used. Prosthetic eyes are covered as well. Members with diabetes are covered for yearly dilated eye exams to screen for retinal disease, and if the screening finds a new condition, follow-up diagnosis and treatment are covered too.10Priority Health. Medical Eye Care Policy
What It Costs
For adults 21 and older, the copay is $2 per vision visit.11Michigan.gov. Healthy Michigan Plan, MIChild and Fee-for-Service Medicaid Handbook Under the Healthy Michigan Plan specifically, copays are billed at the end of each quarter and paid into health savings accounts, and members who participate in specified healthy behaviors can get a reduction in those costs. Total cost-sharing across all services is capped at 5% of household income, and no member can be denied services or lose coverage for failing to pay a copay.12KFF. Medicaid Expansion in Michigan
Well-child visits, which include vision screenings, carry no charge.6Medicaid.gov. Vision and Hearing Screening Services for Children and Adolescents
How to Use the Benefit
You do not need a referral to see an eye doctor.3Priority Health. Vision Care What you do need is a provider who is in your plan’s vision network. Out-of-network care is generally not covered, and you will be responsible for the full cost if you go outside the network. Each managed care plan contracts with a vision vendor to run its eye-care benefits, and the known pairings are:
- Priority Health Choice uses EyeMed.3Priority Health. Vision Care
- Molina Healthcare uses VSP.13Molina Healthcare. Vision Benefits – Healthy Michigan
- Aetna Better Health uses VSP.2Aetna Better Health of Michigan. Vision and Dental Benefits
- UnitedHealthcare Community Plan uses March Vision Care.5March Vision Care. Michigan Provider Reference Guide
- HAP CareSource uses EyeMed.14Health Alliance Plan. Vision Benefit
Blue Cross Complete, McLaren Health Plan, Meridian Health Plan, and Upper Peninsula Health Plan also provide vision benefits, with different vision subcontractors.15Michigan.gov. Medicaid Health Plan Service Area Listing To find an in-network provider, check your plan’s online directory, call member services, or contact the vision vendor directly. Bring your member ID card to the appointment.
If You Have Both Medicare and Medicaid
Medicare generally does not cover routine vision, so for dual-eligible members Medicaid steps in as secondary insurance and adds vision and dental benefits.16Washtenaw Health Project. Medicaid for Seniors and People With Disabilities Medicaid also helps cover Medicare copays, deductibles, and premiums. If you are enrolled in a Dual Eligible Special Needs Plan, bring both your Medicare and Medicaid ID cards to appointments.17Wellcare by Meridian. Vision Benefits Some dual plans include an annual eyewear allowance; UnitedHealthcare’s Dual Complete plans, for example, provide a $200 yearly allowance for frames, lenses, and contacts.9March Vision Care. Michigan Vision Benefits