Colorado’s Medicaid program, known as Health First Colorado, provides eligible residents with comprehensive health coverage, including vision benefits. The scope of this vision coverage is regulated by the state, with benefits varying significantly based on the recipient’s age and the medical necessity of the service. While routine eye care is available, coverage for specialized items like contact lenses is highly restricted and subject to specific medical criteria.
Contact Lens Coverage Based on Medical Necessity
Health First Colorado does not cover contact lenses for routine vision correction. Coverage is strictly limited to cases where they are deemed “medically necessary,” meaning glasses cannot achieve the required level of visual acuity or correct a specific medical condition.
For children and young adults under the age of 21, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program provides broader coverage. Under EPSDT, contacts may be covered if they are the only effective method to correct conditions such as severe keratoconus, high anisometropia (a large difference in prescription between the two eyes), or aphakia (the absence of the eye’s lens).
Adult members, those 21 and older, face a more stringent requirement. For this group, contacts are generally only covered following eye surgery, such as a cataract procedure, if glasses cannot correct the vision post-surgery. Furthermore, even when contacts are medically covered, related supplies like cleaning solutions and contact lens insurance are specifically excluded from the benefit.
Standard Vision Benefits (Exams and Eyeglasses)
Routine eye examinations and standard eyeglasses are the core vision benefits under Health First Colorado. All adult members are entitled to an annual eye examination at no cost, which helps screen for common issues like refractive errors and eye diseases. Children under age 21 also receive routine eye examinations, often without an annual limitation, as part of the EPSDT benefit.
Health First Colorado covers prescription eyeglasses, but the frequency and scope depend on the member’s age. For children and young adults under 21, the program covers one set of eyeglasses, including a frame and either single-vision or multifocal lenses, without a surgical prerequisite. The benefit may also include features like polycarbonate lenses and UV protection.
Adult members 21 and older receive coverage for eyeglasses only if the eyewear is needed following eye surgery. When covered post-surgery, the benefit is limited to one frame and clear plastic or polycarbonate lenses, which can be single or multifocal.
Eligibility Requirements and How to Access Benefits
To utilize Health First Colorado vision benefits, the first step is to confirm active enrollment status through the PEAK system. Checking eligibility ensures the member is currently able to receive services and helps clarify any potential co-payments that may apply.
Many Health First Colorado members are enrolled in a Managed Care Organization (MCO). The MCO may offer additional benefits or have specific provider networks. Members should check their specific plan documentation for details on any supplemental vision coverage. The Health First Colorado website provides a “Find a Doctor” tool, which allows members to search for optometrists and ophthalmologists who accept Medicaid.
When seeking coverage for non-standard items like contact lenses, the treating eye care provider must first determine and document the medical necessity. The provider handles the necessary authorization process with Health First Colorado. Members should always confirm with the provider that they are accepting new Health First Colorado patients before scheduling an appointment.