We get calls almost daily from people who have signed up for Medi-Cal, but have no idea what they have signed up for or what their benefits are.
Medi-Cal has always paid providers much less for procedures than what the doctor's usual fees are from either private patients or other insurance. And it pays for less procedures.
For eye care coverage there are two main parts. One part is for the health of the eye--diseases and injuries--and the other part is for vision. The health part only pays if there is a disease code and does not have a restriction on frequency. The vision part will pay for an exam on an eye that has no disease code, but is limited in frequency to once in 24 months.
Since I am an optometrist most of the calls to our office inquire about vision. Here again, there are two main groups of people with different benefits--children (anyone under 21) or adults 21 and over.
Both children and adults can get a basic eye exam to determine the health of the eyes and the need for glasses once in 24 months. It does not cover a contact lens exam, nor contact lenses, and it does not cover glasses for an adult. Patients therefore have to pay for other services that are not part of the basic exam, such as contact lens exam, or Optos Retinal Exam.
For children, there are guidelines for basic glasses it will cover. It pays less than $20.00 for a frame, and pays optometrist a $22.00 a pair dispensing fee to order, inspect, and adjust clear prescription plastic eyeglass lenses that are manufactured in a prison in Chowchilla, California. Frequency of use for either exam or child's glasses is once in 24 months. No upgrades or frills are allowed on these lenses.
In order to be able to do examination and send a child's glasses to be made it is necessary to have an authorization from the private insurance company (usually VSP) that handles the claim, using the patient's valid Medi-Cal ID number.
Once ordered it takes about 2 weeks to get the child's glasses back from the prison lab.