Vision care, Medicaid/Healthy Michigan Plan patients

Copayments

For members age 21 and older, a $2 copayment per visit applies. Exceptions:

  • Priority Health Choice HMI/Healthy Michigan Plan members don't pay copays for the first 6 months they're enrolled.
  • The final pick-up and fitting of glasses requires no copayment.

Reimbursement

Priority Health reimburses for the services below according to the Michigan Medicaid fee schedule for vision services.

Eye exams

One exam is covered every 24 months to determine the need and proper prescription for corrective lenses.

Vision therapy

Vision therapy (orthotic service) is covered for limited clinical conditions.

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.

Covered lenses include:

  • Standard single vision
  • Standard bifocal (Flattop 25 and 28, round 22mm)
  • Standard trifocals (CV 7/25 and 7/28)

When patients choose more expensive frames and lenses

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.

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.

Services requiring prior authorization

  • Services other than the basic vision benefit must be prior authorized.
  • Two pair of glasses, one for reading and one for distance tasks, are a benefit only if prior authorized and only if the patient's physical condition does not allow bifocal use or if the patient, after a reasonable time, clearly demonstrates an inability to adjust to bifocals.

Exclusions

  • Non-prescription ophthalmic lenses and frames
  • Special independent diagnostic tests or treatment procedures
  • Progressive lenses
  • Oversized lenses and no line lenses

Vision service codes

Code Description
S0620 New patient eye exam, $2.00 copayment applies for age 21 or older
S0621 Established patient eye exam, $2.00 copayment applies for age 21 or older
V2020 Frames purchase
V2100__ Lenses, single vision
V2200__ Lenses, bifocal
V2300__ Lenses, trifocal
92370 or 92371 Repair. Minor adjustments/insertion of screws are not considered repairs.
Last modified: 4/30/2014
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