Health First Colorado, Colorado’s Medicaid program, offers vision services to eligible residents, but eyewear rules are complex. Coverage for contact lenses depends on the distinction between routine vision correction and care for medical conditions. This article clarifies the specific rules and limitations for contact lens coverage under Health First Colorado.
General Vision Benefits for Members
Health First Colorado provides routine eye examinations for all members. Adults aged 21 and older are entitled to one comprehensive eye exam annually to check for refractive errors and eye disease. Children and adolescents 20 years old and younger have access to unlimited eye examinations under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
The standard corrective eyewear provided is eyeglasses, including a frame and lenses. For members 20 and younger, eyeglasses are a standard benefit, with replacement or repair covered when medically necessary. This includes changes in prescription or damage. For adults, coverage for eyeglasses is significantly restricted. Eyeglasses are generally provided only if required for post-operative correction following eye surgery.
Defining Coverage for Contact Lenses
Contact lenses are generally not covered by Health First Colorado for convenience or cosmetic purposes. Coverage is strictly limited to situations where a provider determines they are medically necessary for adequate visual correction. This medical necessity threshold is met only when vision cannot be successfully corrected using standard eyeglasses.
Coverage often applies when an individual has a condition resulting in a highly irregular corneal shape that glasses cannot properly address. Examples include severe astigmatism, aphakia (absence of the eye lens), or keratoconus (progressive thinning of the cornea). These conditions require specialized lenses to conform to the eye’s shape and restore sight, qualifying them for an exception. Prior authorization must be secured from the state or the member’s Managed Care Organization (MCO) before the contacts are ordered.
Eligibility Rules for Adults and Children
A significant difference in coverage exists between adults and children due to federal mandates for pediatric care. Children and adolescents aged 20 and younger benefit from the comprehensive EPSDT program. This program requires that any service necessary to treat a physical or mental health condition must be provided. This broad requirement makes it easier for a child to receive medically necessary contact lenses if glasses prove insufficient.
Adult members aged 21 and older face more stringent rules for contact lens coverage. For this population, contact lenses are generally covered only if required following eye surgery, such as cataract removal, to correct vision. The requirement that glasses must be ineffective remains, even in cases of medical necessity. The overall adult vision benefit focuses primarily on medical treatment for conditions like glaucoma or diabetic retinopathy, rather than routine correction.
Accessing Care and Finding Providers
The initial step in utilizing the vision benefit is verifying current eligibility and coverage status. This can be done by contacting the Health First Colorado Member Contact Center or the member’s Managed Care Organization (MCO). Members must receive eye care from a provider who is actively enrolled and accepts Health First Colorado. Not all optometrists or ophthalmologists participate in the program, so the MCO can provide a list of participating providers.
If the provider determines contact lenses are medically necessary because glasses cannot achieve sufficient correction, they must submit documentation to the state. This documentation must clearly justify the medical necessity and confirm that alternative vision correction is inadequate. The provider is responsible for submitting the necessary paperwork for prior authorization. This process must be completed and approved before the contact lenses are dispensed.