Texas Medicaid provides coverage for vision services and eyeglasses, delivered through programs like Texas Health Steps and the STAR/CHIP managed care system. Benefits vary significantly based on the recipient’s age. For those under 21, the coverage is broad and comprehensive. For adults aged 21 and older, coverage is often limited to medically necessary care or restricted through specific health plan offerings.
Vision Coverage for Children and Youth (Under 21)
Vision coverage for children under age 21 is mandated by the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, implemented in Texas as Texas Health Steps. This program ensures minors receive comprehensive care, including vision, to identify and treat health problems early. The benefit includes a routine eye examination once every 12 months for members age 20 and younger, performed by a Medicaid-enrolled optometrist or ophthalmologist.
Eyewear is provided when medically necessary to correct a vision problem, which includes prescription eyeglasses with standard lenses and frames. These services are generally provided at no cost. The standard benefit allows for one pair of eyeglasses every 24 months, but children often qualify for replacement eyewear sooner.
There is no limit on replacements for eyeglasses that are lost or destroyed. If a child’s eye prescription changes significantly (0.50 diopter or greater), they are eligible for replacement lenses or a new pair of glasses before the two-year period ends. Repairs to damaged glasses are also covered. Contact lenses may be covered only if determined to be medically necessary, such as for aphakia following cataract surgery.
Vision Benefits for Adults (Age 21 and Older)
For Texas Medicaid beneficiaries aged 21 and older, vision benefits are much more restrictive compared to coverage for minors. Routine eye exams for vision correction and standard eyeglasses are generally not guaranteed benefits. Coverage is limited to diagnostic and treatment services related to an illness, injury, or a specific medical condition that directly affects the eye.
Adult coverage focuses on medically necessary eye care to treat conditions such as glaucoma, diabetic retinopathy, or cataracts. For example, Medicaid covers necessary diagnostic tests and post-surgical care, including specialized lenses, for cataract surgery. Repair of nonprosthetic eyeglasses or contact lenses is not a benefit when the cost of materials exceeds a small, set dollar amount.
Some Managed Care Organizations (MCOs) administering STAR, STAR+PLUS, and other Medicaid plans provide supplemental or “value-added” benefits that exceed state minimum requirements. These enhanced benefits can include coverage for one routine eye exam and an allowance for eyeglasses once every 24 months. The allowance for frames and lenses varies by MCO, providing a set dollar amount toward the purchase of eyewear.
Accessing and Utilizing the Benefit
Vision services under Texas Medicaid are primarily coordinated through Managed Care Organizations (MCOs) that administer health plans like STAR, STAR Kids, and STAR+PLUS. Most Medicaid beneficiaries receive their healthcare through these MCOs, which contract with a network of providers. MCOs often subcontract vision benefit administration to third-party Vision Benefit Managers (VBMs) like Superior Vision.
To utilize the benefit, a beneficiary must seek care from an in-network provider who accepts their specific Medicaid MCO plan. The easiest way to find an approved optometrist or ophthalmologist is to contact the MCO directly using the member services number on the health plan ID card. Children covered under Texas Health Steps can also use the statewide call center to find a participating provider.
Services that exceed routine limits may require prior authorization from the MCO before they are performed. This ensures the service is medically necessary before coverage is approved. Beneficiaries enrolled in the STAR Kids or STAR+PLUS programs also have access to specialized service coordination through their MCO.