Does Maryland Medicaid Cover Vision for Adults?

Maryland Medicaid does cover vision for adults, but the real coverage for most enrollees comes from their managed care plan, not the state baseline. Fee-for-service Medicaid gives adults one eye exam every two years and no eyeglasses.1Maryland Health Connection. What Medicaid Covers Every HealthChoice managed care organization adds more on top of that, and most Maryland Medicaid members are in one of those plans.

The State Minimum for Adults

If you are in fee-for-service Medicaid (not enrolled in a managed care organization), your adult vision benefit is one exam every two years. Eyeglasses through fee-for-service are covered only for beneficiaries under 21.1Maryland Health Connection. What Medicaid Covers That’s the floor. Almost everyone gets more than this, because almost everyone is in a HealthChoice plan.

What Your Managed Care Plan Adds

All five HealthChoice MCOs cover an annual eye exam for adults, which already beats the state’s every-other-year rule. Where they differ is how often they’ll pay for glasses or contacts and how much they allow for frames. These extras are voluntary and can change at the start of a calendar year, so confirm the current details with your plan before you shop.2Maryland Health Connection. MCO Comparison Chart

  • Aetna Better Health — one pair of glasses or contact lenses per year, with a $200 frame allowance and $200 for contacts. Aetna’s own materials describe it as “$200 per year toward glasses and contacts” for members 19 and older, administered through Superior Vision.3Maryland Department of Health. HealthChoice MCO Comparison Chart4Aetna Better Health of Maryland. What’s Covered
  • Wellpoint (formerly Amerigroup) — one pair of glasses or contact lenses per year, with a $100 frame allowance and $100 contact lens allowance.3Maryland Department of Health. HealthChoice MCO Comparison Chart
  • Priority Partners — one pair of glasses or contact lenses every two years, with a $150 frame allowance and $200 contact lens allowance. Vision services run through Superior Vision.5Priority Partners. Vision Care
  • Maryland Physicians Care — one set of glasses or contacts every two years, plus one pair of replacement lenses per year when needed. Frame allowance $50, contact lens allowance $100. Services are verified through Superior Vision.3Maryland Department of Health. HealthChoice MCO Comparison Chart6Maryland Physicians Care. Medical Coverage
  • MedStar Family Choice — one pair of glasses or contacts every two years. State documents disagree on the allowance: one comparison chart lists a $19 frame allowance and $100 for contacts, while another lists $150 for frames and $150 for contacts. Check with MedStar directly. MedStar uses the Avesis network rather than Superior Vision.3Maryland Department of Health. HealthChoice MCO Comparison Chart2Maryland Health Connection. MCO Comparison Chart7MedStar Family Choice. Provider Search

Medical Eye Care Is Separate

Cataracts, glaucoma, diabetic eye disease, and eye injuries are not part of the routine vision benefit. They’re treated as medical care under your regular MCO benefits, based on medical necessity, and may require prior authorization.8KFF. Optometrist Services For these conditions, use your MCO’s general medical provider network, not the routine vision network.

If You’re Under 21

Vision benefits for anyone under 21 are broader and federally required through the Early and Periodic Screening, Diagnostic, and Treatment program, which makes vision screening, diagnosis, and treatment (including eyeglasses) mandatory.9MACPAC. Mandatory and Optional Benefits In Maryland, children get one eye exam and one pair of glasses (or contacts in lieu of glasses) per year through their MCO. When a member turns 21, EPSDT no longer applies and the adult rules above take over.

How to Use the Benefit

Which vision company handles your care depends on your plan. Aetna, Priority Partners, Maryland Physicians Care, and Wellpoint use Superior Vision; members can find providers at superiorvision.com or call 800-428-8789.5Priority Partners. Vision Care MedStar Family Choice members use the Avesis network for routine vision, with medical eye care handled through MedStar’s main provider network.7MedStar Family Choice. Provider Search

Some vision services need prior authorization. Maryland Physicians Care, for example, requires services to be verified by Superior Vision before they’re provided.10Maryland Physicians Care. Services Prior Authorization Fee-for-service Medicaid also requires preauthorization for certain professional codes.11Maryland Department of Health. Preauthorization Information Providers usually handle that step, but it’s worth confirming with your MCO before you schedule anything beyond a routine exam.