Medicaid/Healthy Michigan Plan vision services
Vision Care - 91538
Medicaid vision services coverage
Vision therapy (orthotic service) is covered for limited clinical conditions.
Routine eye exams
One exam is covered every 24 months to determine the need and proper prescription for corrective lenses.
New lenses and frames
One pair of single vision, multi-focal or cataract lenses and frames is covered every 24 months and one day. Ophthalmic lenses include standard crown glass or CR 39 plastic lenses in all sizes and powers.
Patients must pay the difference between the plan's allowed amount and the cost of frames and lenses when purchasing more expensive ophthalmic frames and or lenses.
Covered lenses include:
- Standard single vision
- Standard bifocal (Flattop 25 and 28, round 22mm)
- Standard trifocals (CV 7/25 and 7/28)
Repair of lenses and frames
Repairs are covered. Minor adjustments/insertion of screws are not considered repairs.
Replacement lenses and frames
Replacement of frames/lenses due to loss or breakage (if they cannot be repaired) is covered once every 12 months for adults 21 and older, and twice for those under 21.
Replacement glasses must be an identical replacement of the previously issued glasses unless they are no longer available.
Medically necessary replacement lenses are a covered benefit if there has been a significant change in the member's vision.
- Non-prescription ophthalmic lenses and frames
- Special independent diagnostic tests or treatment procedures
- Progressive lenses
- Oversized lenses and no-line lenses
Medicaid vision services billing
Priority Health reimburses for vision services according to the Michigan Medicaid fee schedule.
Medical vision service codes
See the Priority Health Vision Care medical policy above for details on codes and coverage.
Ophthalmologist/optometrist billing for cataract surgery & services
See Procedures & services > Medical/surgical > Cataract surgery for billing details.
Contact lens evaluation billing, 92310
Either an ophthalmologist or optometrist may bill 92310, contact lens evaluation.
Benefit language states that this service is included in the contact lens limitation. If contact lens benefit has not been met, all or a portion of the 92310 could be paid. However, once the patient has met their benefit limit for the contacts, 92310 will be denied as member liability.
- Bill 92310 only at the time of original contact lens prescription and fitting.
- When the provider performs a contact lens evaluation over and above the standard eye exam, bill either an S0620 or S0621 (standard eye exam) and the 92310.