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Learn about MassHealth vision care services

Vision care is one of many benefits available to children and adults who are enrolled in MassHealth.

Vision care includes services like eye exams, eyeglasses and repairs, and other benefits. In general, you are eligible for vision care benefits if you are enrolled in one of the following coverage types:

  • MassHealth Standard
  • MassHealth CommonHealth
  • MassHealth Careplus
  • MassHealth Family Assistance

Members enrolled in One Care, Senior Care Options (SCO) or the Program of All-inclusive Care for the Elderly (PACE) should contact their One Care plan, SCO, or PACE organization directly for assistance with vision care services.

Table of Contents

Covered vision care services

This chart shows the vision care services that are covered for children and adults who have MassHealth Standard, MassHealth CommonHealth, MassHealth Careplus, and MassHealth Family Assistance.

Service

Is it Covered?

Is a Prior Authorization Needed?

Important Notes

Eye Exam (includes vision screening)

YES

NO

Members younger than 21 years old: Once every 12 months (No referral required)

Members 21 years and older: Once every 24 months (No referral required)

Members may be covered for more frequent eye exams with a referral from a physician or if certain medical conditions exist.

See additional notes below for details.

New eyeglasses

YES
One initial pair.

NO

Members younger than  21 years old: Once every 12 months

Members 21 years and older: Once every 24 months

Members who need bifocals may be able to get two pairs of glasses instead of bifocals, if certain criteria are met.

See additional notes below for details.

New eyeglass frames

YES
With a prescription that meets certain criteria.

NO

Members younger than 21 years old: Once every 12 months

Member 21 years and older: Once every 24 months

Broken eyeglasses repair or replacement

YES

Sometimes - see notes to the right

Glasses must be repaired or replaced by the optician who ordered the initial eyeglasses.

Members 21 years and older: Requires Prior Authorization if repair is requested within 24 months of when glasses were dispensed.

Lost eyeglasses replacement

YES

Sometimes - see notes to the right

Members under 21 years old: one replacement pair every 12 months without prior authorization

Members 21 years and older: one replacement pair every 24 months without prior authorization

Prior Authorization is required if more than one replacement is needed within the time periods noted above.

Prescription updates to eyeglass lenses

YES

YES

A prescription change from a valid provider is required.

Plano Lens (PL)

YES

NO

Benefit coverage/limitations for spectacles are based on medical necessity- talk to your provider for more information.

Tinted lenses

(Pink 1 and Pink2)

YES

NO

Pink 1 and Pink 2

See additional notes below for details.

Tinted lenses other than Pink

YES
Plastic lenses only

YES

An Optometrist or Ophthalmologist can request prior authorization for alternative tint options based on medical necessity.

Contact lenses

YES

NO

Hard, soft or gas-permeable lenses, if specific conditions are met: see additional notes below for details; 

coverage/limitations for contact lenses are based on medical necessity-talk to your provider for more information.

Extra or spare eyeglasses

YES

YES

See additional notes below

Additional notes on eye exams: These restrictions do not apply if there is a referral from the member's physician or if one of the following complaints or conditions is documented in the member's record: (a)blurred vision; (b) evidence of headaches; (c) systemic diseases such as diabetes, hyperthyroidism, or HIV; (d)cataracts; (e) eye pain; (f) eye redness; (g) eye infection; (h) double vision; or (i) members receiving long term therapeutic drugs which may cause ocular side effects. MassHealth does not pay for more than two screening services in a 12-month period.

Additional notes for members who need bifocals: MassHealth pays for two pairs of eyeglasses instead of bifocals if one or more of the following conditions exists and is fully documented in the member’s medical record: (a) The member's prescription cannot satisfactorily be made into bifocal lenses; or (b) The member has shown an inability to adjust to bifocals; or (c) The member has a physical disability or medical condition(for example, severe arthritis) that would preclude or impede adjustment to bifocals; or (d) The member's advanced age would make adjustment to bifocals unduly difficult; or (e) The member's occupation would make bifocals hazardous; or (f) The member has a marked facial asymmetry.

Additional notes on pink tinted lens coverage: MassHealth covers pink tinted lenses if (a) the member has a pathological or other abnormal condition such as aphakia; or (b) the member has habitually worn tinted lenses of this nature, and the prescriber concludes that the member should continue to wear them. MassHealth does not pay for tinted lenses prescribed only because the member complains of photophobia.

Additional notes on contact lens coverage: MassHealth pays for hard, soft, or gas-permeable contact lenses if one or more of the following conditions exists: (a) postoperative cataract extraction; or (b) keratoconus; or (c) anisometropia of more than 3.00D; or (d) more than 7.00D of myopia or hyperopia.

Additional notes on extra or spare eyeglasses: MassHealth pays for an additional pair when one or more of these conditions exist: aphakia,> 7.00D of myopia or hyperopia, or >3.00D of astigma.

Additional notes on eyeglasses: MassHealth members must choose their frames and lenses from the MassCor Vision Catalog. To view the prescription eyewear options available through MassHealth, you can visit MassCor Industries - OPTICAL or ask your provider if they hold a copy of the latest catalog that can be used at the time of your appointment.

Prior authorization for vision care services

Some services may need to be approved by MassHealth first. This process is called a prior authorization.

Depending on the type of vision service you need, your provider may need to send a prior authorization directly to MassHealth or your MassHealth health plan. Your provider should know which services these are and will request approval if they feel that you need these services. If you or your provider have questions about prior authorizations, contact the MassHealth Customer Service Center or your MassHealth health plan.

Who to call if you have questions about covered services or need help finding a provider

If you are enrolled in a MassHealth Accountable Care Partnership Plan (ACPP) or a Managed Care Organization (MCO), medical-related visual services like vision exams will be covered by your health plan and will need to be done by a provider within your ACO’s or MCO’s network.

Other services like glasses, visual aids, and similar materials, are covered directly by MassHealth, and you can use any MassHealth provider to obtain these benefits. If you are enrolled in an ACCP or MCO, you should call your health plan first with questions about vision care. If the vision care you’re looking for is a service covered directly by MassHealth, your health plan will transfer you to the MassHealth Customer Service Center to answer these questions.

If you are enrolled in a Primary Care ACO or the Primary Care Clinician (PCC) Plan, vision care is covered directly by MassHealth and you will need a referral from your primary care provider for vision care services. Questions about your vision care services or how to find a vision care provider should be directed to the MassHealth Customer Service Center.

If you are enrolled in One Care, Senior Care Options (SCO), or the Program of All-Inclusive Care for the Elderly (PACE), all vision care questions should go directly to your One Care or SCO plan, or PACE organization. 

MassHealth members who have private health insurance also known as third party liability (TPL)

MassHealth members can have both MassHealth and private health insurance (or Medicare) at the same time. If you have both types of insurance, the private health insurance (or Medicare) is considered a liable third party or “TPL.” This means the private health insurance (or Medicare) is billed as the primary insurer and MassHealth is the secondary coverage.

In order to have MassHealth pay for your vision care, including the cost of copays, deductibles and other out of pocket costs, you must follow the rules of your private health insurance plan and see a provider who is in both the private plan network and in the MassHealth network. Please make sure to ask all providers before scheduling an appointment if they accept MassHealth and your private health insurance. For more information about private insurance and MassHealth visit MassHealth and private health insurance also known as Third Party Liability (TPL).

Vision care resources from the Department of Developmental Services

Individuals with Intellectual and Developmental Disabilities may also find additional resources from the Department of Developmental Services (DDS). 

For more information, please visit the DDS website.

Vision care services for MassHealth Limited members

MassHealth Limited covers treatment of emergency medical conditions that could result in placing your health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. MassHealth Limited does not cover preventative or non-emergency vision care services.

If you have questions about vision care services and these programs, you should contact the MassHealth Customer Service Center.

Vision services covered by the Children’s Medical Security Plan (CMSP)

If you are enrolled in Children’s Medical Security Plan (CMSP), MassHealth will only pay for annual and medically necessary eye exams. For more information about vision services covered in CMSP, contact the MassHealth Customer Service Center.

Vision care services that may be paid through Health Safety Net (HSN)

The Health Safety Net (HSN) will only pay for services provided by a community health center or an acute hospital, which includes hospital-licensed health centers or hospital satellite clinics. In order for the HSN to pay for vision care services rendered, the services must be provided in one of those settings. The HSN is the payor of last resort and will only pay for services rendered in the settings for low-income patients when there is no available insurance or other third party payor available.

For more information, contact Health Safety Net at (877) 910-2100 or visit https://www.mass.gov/service-details/health-safety-net-for-patients.

 

Contact

Phone

Self-service available 24 hrs/day in English and Spanish. Other services available Monday-Friday 8 a.m.–5 p.m. Interpreter service available.

Self-service available 24 hrs/day in English and Spanish. Other services available Monday-Friday 8 a.m.–5 p.m. Interpreter service available.

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