Does Medicaid Cover Vision in Utah? Adults, Children, and Providers

Utah Medicaid covers routine eye exams for every enrolled member, but it only pays for eyeglasses and contact lenses for children under 21 and pregnant members. Non-pregnant adults aged 21 and older can get the exam covered, but not the glasses the exam might prescribe.1Utah Department of Health & Human Services. November 2024 Medicaid Information Bulletin

What Adults Get

If you are 21 or older and not pregnant, Utah Medicaid pays for one routine eye exam per rolling year with an optometrist or ophthalmologist. Additional exams are allowed when medically necessary or when glasses have been lost or broken.1Utah Department of Health & Human Services. November 2024 Medicaid Information Bulletin

As of May 1, 2025, the program also covers a refraction exam once per rolling year. This is the standard test that produces a glasses prescription, billed under CPT code 92015, and it is covered on top of the other eye exam codes.2Utah Department of Health & Human Services. May 2025 Medicaid Information Bulletin

What Medicaid will not do for adults is pay for the glasses themselves. Eyeglasses and contact lenses are excluded from adult coverage unless the member is pregnant.1Utah Department of Health & Human Services. November 2024 Medicaid Information Bulletin If you get a service Medicaid does not cover, you owe the cost, and the provider should have you sign a form stating the service, that Medicaid does not cover it, and the amount you will pay.3Utah Department of Health & Human Services. Utah Medicaid Member Guide 2025

What Children Under 21 Get

Coverage widens considerably for members under 21. Through the federal Early and Periodic Screening, Diagnostic and Treatment benefit (EPSDT), Utah Medicaid covers vision screenings, diagnosis, and treatment of vision defects, including eyeglasses.4Medicaid.gov. Early and Periodic Screening, Diagnostic and Treatment If a provider determines a child needs a vision service that isn’t ordinarily covered for adults, EPSDT can still cover it when it is medically necessary.5Utah Medicaid. Early and Periodic Screening, Diagnostic and Treatment

For eligible children, Medicaid pays for one pair of eyeglasses every 12 months. Replacement glasses are also allowed once per 12-month period. Replacement lenses that reuse the existing frames don’t need prior authorization; replacing frames sooner than 12 months does.6Utah Department of Health & Human Services. EPSDT Services Provider Manual

A new pair can be authorized before the 12 months are up in specific situations:

  • A prescription change of 0.5 diopters or more
  • A medically necessary change identified during an exam
  • A change in head size
  • An allergic reaction to the previous pair
  • Original glasses that are lost, broken, or irreparably damaged, with a written statement explaining what happened

Glasses lost or broken through a member’s abuse or neglect are not replaced. Extra pairs (reading glasses, safety glasses, or spares) are not covered either.7Utah Department of Health & Human Services. EPSDT Services Provider Manual (2023)

Contact Lenses

Contact lenses are covered only when medically necessary, not as a routine substitute for glasses.8Molina Healthcare. Utah Medicaid Vision Services Across Medicaid programs, that generally means situations where vision cannot be adequately corrected with glasses, such as after cataract surgery or for conditions like aphakia, and prior authorization is almost always required.9National Academies. Medicaid Vision Coverage by State Your provider handles the authorization request; members do not file these themselves.10Utah Department of Health & Human Services. Utah Medicaid Member Guide 2024

Copays for Eye Care

Adult members who are subject to copays pay $4 per visit with an optometrist and $4 per visit with an ophthalmologist. These count toward a combined $100 annual out-of-pocket maximum that also covers physician visits, podiatry, and outpatient hospital services.11University of Utah Health Plans. Healthy U Medicaid Member Handbook

You pay no copays at all if you fall into any of these groups:

  • Members under age 18
  • Pregnant members
  • American Indians and Alaska Natives
  • Members receiving hospice care
  • Members eligible for Cancer Medicaid
  • Targeted Adults Medicaid (TAM) members
  • Members with TANF or Family Employment Program (FEP) eligibility

Members who have other insurance, including Medicare, may also be exempt.12Utah Department of Health & Human Services. Medicaid Copay Chart

Finding a Vision Provider

Vision benefits are delivered through Utah’s managed care organizations, and the covered vision services are the same across plans.13Medicaid.gov. Utah Managed Care Delivery Systems To find an in-network eye doctor, go through your plan:

Bring your Medicaid card and, if you’re in a managed care plan, your plan card. A government-issued photo ID may be requested. If you have other health insurance, bring those cards too.10Utah Department of Health & Human Services. Utah Medicaid Member Guide 2024

If Your Child Is on CHIP, Not Medicaid

Children in Utah’s Children’s Health Insurance Program have narrower vision benefits than children on full Medicaid. CHIP covers eye exams and vision screenings but does not cover eyeglasses to correct refraction or eye surgery to correct vision. Benefits are identical across SelectHealth, Molina, and Healthy U. Copays for a vision screening are $5 on Plan B (one per year) and $25 on Plan C. Verified American Indian and Alaska Native children pay no copays, deductibles, or coinsurance.16Utah CHIP. CHIP Members Guide 2024

Because CHIP doesn’t pay for glasses, families sometimes turn to charity. Friends for Sight, a Utah organization operating since 1955, provides free eye exams and glasses to people in need.17Friends for Sight. Friends for Sight National programs including VSP Eyes of Hope (for families at or below 200 percent of the federal poverty level) and New Eyes also provide free prescription eyeglasses.18National Eye Institute. Get Free or Low-Cost Eye Care

If You Have Both Medicare and Medicaid

Adults who qualify for both Medicare and Medicaid can enroll in a Medicare Advantage Dual Special Needs Plan, and those plans often add vision benefits Medicaid alone doesn’t provide.3Utah Department of Health & Human Services. Utah Medicaid Member Guide 2025 The UnitedHealthcare Dual Complete plan for Utah in 2026, for example, includes a $0 copay routine eye exam each year, a $200 annual allowance for frames or contact lenses, and full coverage of standard prescription lenses with scratch-resistant coating.19UnitedHealthcare. UHC Dual Complete UT Summary of Benefits 2026 The SelectHealth Medicare Dual plan lists $0 copays for routine eye exams, contact lenses, and eyeglass frames and lenses, subject to limits.20Q1Medicare. SelectHealth Medicare Dual Plan Benefits For an adult who needs glasses that standard Medicaid won’t cover, dual-eligible enrollment is worth a look.