CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy N/A

Eyewear and Vision Care Services

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This policy governs Vermont Medicaid coverage of vision care services, eyeglasses, contact lenses, and other aids to vision. Vision care services are available to beneficiaries of any age, while eyewear coverage is limited to beneficiaries under age 21 and subject to provider, frequency, replacement, and prior authorization requirements.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyEyewear and Vision Care Services

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Medicaid Fee Schedule and obtain prior authorization when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Any ageVision care service eligibility

Under 21Eyewear coverage age limit

2 yearsRoutine eye exam benefit period

1 pair/yearFrames under age six

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CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy N/A

Eyewear and Vision Care Services

Customize your policy alerts

Sign up for all Vermont Agency of Human Services – Department of Vermont Health Access policy alerts

Know when Vermont Agency of Human Services – Department of Vermont Health Access releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyEyewear and Vision Care Services

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Medicaid Fee Schedule and obtain prior authorization when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Any ageVision care service eligibility

Under 21Eyewear coverage age limit

2 yearsRoutine eye exam benefit period

1 pair/yearFrames under age six

1 pair/2 yearsFrames ages six through 20

0.5 diopterEarlier replacement threshold

Covered Vision Care Services

Eligibility and qualified providers

Covered when all applicable provider and beneficiary requirements are met.

Vision care eligibility: The beneficiary is eligible for vision care services, which are available at any age; if the service is eyewear, the beneficiary is under age 21.Eyewear: under age 21

Qualified provider: The service is provided by a licensed physician skilled in diseases of the eye or an optometrist working within the scope of practice and enrolled in Vermont Medicaid. Eyeglass-dispensing services may be provided by an optician, optometrist, or ophthalmologist.

Eyeglasses and their repairs or replacements are provided through the Department of Vermont Health Access contracted vendor.

Routine eye examinations

Covered when either routine eye exam frequency option is met within a two-year period.

Routine eye exam frequency: Within a two-year period, the beneficiary receives either one comprehensive eye exam and one intermediate eye exam, or two intermediate eye exams.One comprehensive plus one intermediate exam per two years OR two intermediate exams per two years

Exams must be provided by an ophthalmologist or optometrist enrolled in Vermont Medicaid.

Non-eyewear aids to vision

Covered when all functional criteria are met.

Non-eyewear aid to vision: The beneficiary is legally blind and the aid to vision will foster independence by improving at least one activity of daily living or instrumental activity of daily living.Legally blind; improvement in at least one ADL or IADL

Examples include closed-circuit television.

Eyeglasses for beneficiaries under age six

For beneficiaries under age six, coverage is limited to the following frequencies.

Eyeglasses under age six: The beneficiary is under age six and the requested items remain within the applicable annual limits: one pair of eyeglass frames, one new lens per eye, and one fitting.1 frame pair per year; 1 new lens per eye per year; 1 fitting per year

Eyeglasses for beneficiaries ages six through 20

For beneficiaries ages six through 20, coverage is limited to the following frequencies.

Eyeglasses ages six through 20: The beneficiary is age six through 20 and the requested items remain within the applicable two-year limits: one pair of eyeglass frames, one new lens per eye, and one fitting.1 frame pair per two years; 1 new lens per eye per two years; 1 fitting per two years

Earlier eyeglass replacement

Earlier replacement is covered when at least one permitted circumstance applies, unless medically necessary.

Permitted earlier replacement circumstances: The eyeglasses have been lost; broken beyond repair; have lenses scratched enough to compromise visual acuity; the beneficiary's vision has changed by at least one-half diopter in a single lens; or frame size changed because of a significant inter-pupillary-distance change.Vision change of at least 0.5 diopter in a single lens

Earlier replacement is otherwise limited unless medically necessary.

Provider and Billing Actions

Prior Authorization

Check the Vermont Medicaid Fee Schedule

Review the Vermont Medicaid Fee Schedule before billing to determine whether the service requires prior authorization. The Fee Schedule lists covered services and identifies services subject to prior authorization.

Denial Risk

Confirm Eyewear Age Eligibility

Eyewear coverage is limited to beneficiaries under age 21. Claims for eyewear furnished to a beneficiary age 21 or older may be denied, although vision care services are available to beneficiaries of any age.

Confirm the beneficiary is under age 21 before billing eyewear.
Vision care services, including covered exams, may be provided to beneficiaries of any age.

Policy Background

Vision care services include the diagnosis and treatment of vision and vision disorders, including the prescription of therapeutic drugs. Covered services include refraction, eye examinations, diagnostic testing, and certain non-eyewear aids to vision, such as closed-circuit television, when the beneficiary is legally blind and the aid improves at least one activity of daily living or instrumental activity of daily living.

Vision care services are available to beneficiaries of any age. Eyewear includes eyeglasses, contact lenses, and other aids to vision prescribed by an optometrist or a licensed physician skilled in diseases of the eye; coverage of eyewear is limited to beneficiaries under age 21. Eyeglasses and their repairs or replacements are provided through the Department of Vermont Health Access' contracted vendor.

Key Definitions

Vision care services

DefinitionServices, and the prescription of therapeutic drugs, related to the diagnosis and treatment of vision and vision disorders.

Eyewear

DefinitionEyeglasses, contact lenses, and other aids to vision prescribed by an optometrist or a licensed physician skilled in diseases of the eye.

Eyeglasses

DefinitionLenses and/or frames.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyEyewear and Vision Care Services

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Medicaid Fee Schedule and obtain prior authorization when indicated.

SourceLink

On This Page

Denial Risk

Verify Provider Qualification and Enrollment

Vision care services must be provided by an appropriately qualified provider who is enrolled in Vermont Medicaid. Claims may be denied when licensure, scope-of-practice, or Medicaid enrollment requirements are not met.

A licensed physician skilled in diseases of the eye or an optometrist working within the scope of practice may provide vision care services.
Refractions and eye exams must be provided by an ophthalmologist or optometrist enrolled in Vermont Medicaid.
An optician, optometrist, or ophthalmologist may provide eyeglass-dispensing services.
Eyeglasses, repairs, and replacements are provided through the Department of Vermont Health Access contracted vendor.

Denial Risk

Check Frequency Limits

Check applicable frequency limits before billing routine eye exams or eyewear components. Claims may be denied when the beneficiary has already reached the applicable limit.

Routine exams: one comprehensive and one intermediate exam within a two-year period, or two intermediate exams within a two-year period.
Beneficiaries under age six: one pair of frames per year, one new lens per eye per year, and one fitting per year.
Beneficiaries ages six through 20: one pair of frames per two years, one new lens per eye per two years, and one fitting per two years.

Denial Risk

Validate Early Replacement Circumstances

Earlier replacement of eyeglasses is limited to specified circumstances unless the replacement is medically necessary. Claims for replacements that do not meet a permitted circumstance may be denied.

Eyeglasses were lost.
Eyeglasses were broken beyond repair.
Lenses are scratched enough to compromise visual acuity.
The beneficiary's vision changed by at least one-half diopter in a single lens.
Frame size changed because of a significant change in interpupillary distance.

Prior Authorization

Obtain Required Prior Authorization

Obtain prior authorization whenever the Vermont Medicaid Fee Schedule indicates that authorization is required. Claims may be denied when required authorization was not obtained before the service was provided.

Use the current Vermont Medicaid Fee Schedule to identify services requiring prior authorization.
Document and retain the authorization in accordance with applicable billing requirements.