Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The following vision services are covered under Medi-Cal plans:
- Routine eye examination and refraction every two years (service date to service date).
- Annual diabetic retinal eye examinations by an ophthalmologist or optometrist for members who have been diagnosed with diabetes.
- Second eye examination with refraction within two years is covered only when the criteria for replacement lenses and the following criteria are met:
- The member is unable to return to or obtain the prescription from the previous provider.
- The examination is necessary to determine a change in vision.
- Medically necessary eye exams by ophthalmologists or optometrists for acute or urgent care.
- Contact lenses, when medically necessary, for eligible members under age 21 or members residing in skilled nursing facilities (SNFs). Adults ages 21 and older are covered for bandage contacts only when medically necessary; other opthalmological materials are not covered.
Frames and Lenses
- Optical lenses and frames are covered every two years (service date to service date).
Polycarnonate Lenses
Polycarbonate lenses are covered for:
- Visual impairment in one or both eyes where the optimal correction is equal to or less than 0.30 decimal or 20/60 Snellen or equivalent at specified distances.
- Either visual field is limited to 10 degrees or less from the point of fixation in any direction.
Note: Optical lenses are made by California Prison Industry Authority (CALPIA) optical laboratories and provided without cost through the optometrist’s or ophthalmologist’s office participating with Envolve Vision for those identified above.
Frame Replacement and Repair
- Replacement within two years of initial coverage is limited to the same model whenever feasible.
- Replacement frames within two years are not covered if an existing frame can be made suitable for continued use by the following:
- Adjustment
- Repair of broken frame
- Replacement of broken frame part
Replacement Lenses*
Replacement is covered when:
- The power is changed at least 0.50 diopters in any corresponding meridian.
- The cylinder axis is changed 20 degrees or greater for cylinder power of 0.50 - 0.62 diopters, 15 degrees or greater for cylinder power of 0.75 - 0.87 diopters, 10 degrees or greater for cylinder power of 1.00 - 1.87 diopters, or 5 degrees or greater for cylinder power of 2.00 diopters or greater. Change in axis of cylinder power of 0.12 - 0.37 diopters, as the sole reason for change, is not covered.
- The prismatic differential correction is changed at least 0.75 prism diopters in the vertical meridian or at least 1.5 prism diopters in the horizontal meridian.
- The previous lens is lost, stolen, broken or marred to a degree significantly interfering with vision or eye safety.
- A different frame size or shape is necessary due to patient growth, metal allergy or other justifiable medical reasons.
*Replacement lenses should be ordered directly through the CALPIA optical laboratories.
Low Vision Examinations and Aids
- Low vision examinations and aids (including the fitting) are covered if:
- The best corrected visual acuity is 20/60 or worse in the better eye, or there is a field restriction of either eye to 10 degrees or less from the fixation point.
- The condition causing subnormal vision is chronic and cannot be relieved by medical or surgical means.
- The physical and mental condition of the recipient is such that there is a reasonable expectation that the aid will be used to enhance the everyday function of the recipient.
- The aid prescribed or provided is the least costly type that will meet the needs of the recipient.
Contact Envolve Vision to refer members or arrange visits. Envolve Vision optometrists or ophthalmologists arrange orders and dispense lenses and frames, if indicated.
For River City Medical Group (RCMG) members, contact RCMG. For Molina Healthcare members, contact March Vision Care.
The primary care physician (PCP) is the primary screener for ocular abnormalities requiring referral for a comprehensive eye examination. Comprehensive eye examinations performed by an optometrist or ophthalmologist are covered for all Medi-Cal members.
Providers should refer to the Health Net Provider Directory for a list of participating optometrists and ophthalmologists. Providers may contact the Health Net Medi-Cal Provider Services Center, CalViva Health Medi-Cal Provider Services Center (for Fresno, Kings and Madera counties) or Community Health Plan of Imperial Valley Provider Services Center.
All children should undergo an evaluation to detect eye and vision abnormalities during the first few months of life and again at about age three. Children between ages four and six should have a comprehensive eye examination in addition to the screening performed by the PCP. Children with prescription eyewear or contact lenses should have an eye examination annually.
Referrals to ophthalmologists or optometrists for non-routine eye problems should be directed and coordinated by the PCP or PPG. Children with one or more of the following should have a comprehensive eye evaluation by an ophthalmologist:
- Abnormalities detected in the screening evaluation.
- Signs or symptoms of eye problems.
- History of eye problems.
- Multiple health problems, systemic disease or use of medications that are known to be associated with eye disease and vision abnormalities.
- Family history of conditions that cause, or are associated with, eye or vision problems.
- Health and developmental problems that make screening by the PCP difficult or inaccurate.
Members may self-refer without authorization to obtain annual routine vision services from a participating optical provider. Health Net and Molina Healthcare each contract with a specific panel of optometric providers. These providers are listed in the provider directory. Providers may contact the Health Net Medi-Cal Member Services Department to obtain the most recent provider directory.
Non-routine visits, such as evaluation of apparent or potential ocular abnormalities are coordinated through the primary care physician (PCP).
In some cases, the participating physician group (PPG) may contract with a panel of vision providers. Members must direct questions about the vision network to their PPG for Medi-Cal member referral purposes.
Members may self-refer to obtain annual routine vision services from a participating optical provider. Members should refer to the Health Net provider directory for participating optometrists. Members may contact the Health Net Medi-Cal Member Services Department, CalViva Health Medi-Cal Member Services Department (for Fresno, Kings and Madera counties) or Community Health Plan of Imperial Valley Member Services Department. to obtain the most recent provider directory.
Filling Lens Prescriptions
The participating optical provider sends the lens prescription and frame order to the California Prison Industry Authority (CALPIA) laboratory for production.
The PIA laboratory manufactures the lenses, inserts them into the frames, and returns them to the dispensing provider.
Fittings
Once the glasses are received in the optical provider's office, the participating optical provider ensures that each member receives an appointment for an eyeglass fitting and adjustment.
Members may self-refer for routine vision services from a participating optical provider every two years. Members all ages have additional benefits for lenses and frames provided by the California Prison Industry Authority (CALPIA) every two years.
Additionally, medical eye exams (to monitor diabetes, hypertension and other medical conditions) are available as medically necessary, generally on an annual basis or as indicated by the primary care physician (PCP) or treating specialty ophthalmologist.
Health Net contracts with Envolve Vision (to provide vision benefits to Health Net Medi-Cal members; however, River City Medical Group (RCMG) members must contact RCMG and Health Net members assigned to Molina Healthcare must contact March Vision Care.
The following are not covered:
- Eyeglasses used primarily for protective, cosmetic, occupational, or vocational purposes.
- Eyeglasses prescribed for reasons other than the correction of refractive errors or binocularity anomalies.
- Progressive lenses.
- Orthoptic and/or pleoptic training.
- Prescription eyeglasses for alternative use by a person who has and is able to wear contact lenses.
- Upgraded frames or non-standard lenses, unless when meeting medical necessity.
- Prosthetics (may be covered by the health plan/medical group).
- Surgical professional services normally performed by an ophthalmologist (may be covered by the health plan/medical group).
- Multifocal contact lenses.
- Eyewear for members ages 21 and older, unless residing in a skilled nursing facility or intermediate care facility or for pregnancy related services for the treatment of other conditions that might complicate the pregnancy.