Please note: The new FAQs and IR MA13-06 were posted on 4/4/13
House Bill 260 Budget Reductions affecting Vision Services became effective July 1, 2011. They are described in Medicaid Information Release MA11-11 as follows: Idaho Medicaid will no longer cover vision services for adults unless they require evaluation and treatment for a chronic disease such as diabetes. There are no changes for vision services for participants who are under the age of 21.
If you are a Medicaid participant with questions about benefits, please contact your Medicaid vision provider who will be able to assist you based upon your individual medical situation. Molina Medicaid Solutions Customer Service is also available at 1 (866) 686-4272.
Please see the Provider Handbook for specific information about Vision Benefits. Under Provider Guidelines, see Eye and Vision Services (revised November 2011). The handbook also explains which services and supplies do or do not require prior authorization. See the Medicaid Rules sections 781-785 for details Vision Services.
For participants age 21 and over, the following is a general overview of benefits, but is not a complete discussion: Vision examinations and some other services are covered for chronic conditions that may damage the eye. For example, examinations are covered for adults with diabetes and many other medical conditions which affect the eye. Eyeglass lenses and frames are covered for adults following cataract surgery according to Medicare guidelines. Eyeglass lenses and frames are not covered for routine vision correction for adults, or for those with a chronic condition affecting the eyes. Contact lenses are only covered for adults if there is a serious condition which progressively degrades vision, such as keratoconus. Removal of foreign bodies, repairs of lacerations, and other treatment for acute conditions that would result in permanent damage to the eye, if left untreated, are covered. Vision providers may submit requests, with supporting documentation, for medical conditions which do not meet criteria noted in the handbook. These special requests will be discussed with Medicaid’s Medical Director for a medical determination.
Providers should bill all vision services for adults age 21 and over with a diagnosis code to indicate the chronic condition requiring those services.
If you have questions about the changes in vision benefits, please contact the policy subject matter expert for the Division of Medicaid at (208) 364-1818 or you can send us an email. Idaho Medicaid Vision Services are provided on a fee for service basis from local ophthalmologists, optometrists, and opticians. Contacts and eyeglasses which meet Medicaid criteria are provided through a contract with Barnett and Ramel Optical. For questions about the B&R contract please contact (208) 287-1177. The Medical Care Unit's phone number is (208) 364-1904. The Medical Care Unit is responsible for monitoring this contract and for reviewing and authorizing certain vision products and some eye examinations. Prior authorization faxes may be sent to (877) 314-8779. Please see the specific Prior Authorization Request Forms in the right hand column of this webpage. Vision providers may see the outcome of the review under their Trading Partner Account, HealthPAS, Authorization Status, or by inquiring with Molina Medicaid Solutions at (866) 686-4272.