Coverage of Vision Services under the State Children's Health Insurance Program (SCHIP)

Coverage of Vision Services under the State Children's Health Insurance Program (SCHIP)

Order Code RL32628
CRS Report for Congress
Received through the CRS Web
Coverage of Vision Services under the State
Children’s Health Insurance Program (SCHIP)
October 12, 2004
(name redacted)
Analyst in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

Coverage of Vision Services under the State Children’s
Health Insurance Program (SCHIP)
Summary
A small but significant proportion of children have visual impairments. When
detected early, many childhood vision abnormalities are treatable, but the potential
for correction and normal visual development diminishes with age. Under SCHIP,
states may provide coverage by expanding Medicaid or creating a separate SCHIP
program or both. Medicaid and SCHIP provide access to an array of vision-related
services, including vision screening services that can help children in low- to
moderate-income families overcome these difficulties.
Medicaid’s mandatory Early, and Periodic, Screening, Diagnosis, and Treatment
(EPSDT) benefit ensures access to vision screening services for children. However,
there are several other Medicaid benefit categories where vision screening services
may be delivered. Often such services are billed as a part of a well-child visit. Under
SCHIP, state-specific benefit packages must provide well-baby and well-child care,
which includes a vision screening component. As with Medicaid, the well-child
coverage requirement is not the only service category where children could receive
vision screening under SCHIP. Children may also receive vision screening services
under other SCHIP-covered services such as physician services.
A June 2000 CRS benefits survey provides some clues as to access to vision
services under SCHIP Medicaid expansion and separate state programs. At that time,
nearly all Medicaid and SCHIP programs covered vision services for children, and
most also covered eye glasses. The survey data indicates that the breadth of vision-
related benefits available under these two programs likely differs within and across
states.
Coverage policies and benefit limits for the lowest-income children as described
in state Medicaid plans are seldom absolute because of EPSDT. For nearly all
Medicaid children, states are required to provide all federally allowed treatment to
correct identified problems, even if the specific treatment needed is not otherwise
covered under a state’s Medicaid plan. As a result, when a Medicaid agency reports
that a specific benefit is not covered for children, that means the service is available
only when delivery of that service meets the EPSDT requirement.
Services for higher-income children under SCHIP are sometimes more
restrictive. Unlike Medicaid, but consistent with federal statute, separate SCHIP
programs are modeled after private sector, commercial insurance products. The
requirement to use benchmark plans (or actuarial equivalents of those plans), most
of which are state employee health plans or commercial HMO plans, provides the
framework for defining benefit limits. Under commercial insurance products,
benefits are always limited by medical necessity, but other limits may apply and will
vary by insurance product, as do procedures to monitor for medical need and
appropriateness. Payments to providers participating in these plans may be altered
based on the outcome of such service utilization reviews, which can in turn affect
access to care. This report will not be updated.

Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
What Are Vision Services and What Types of Providers
Deliver Vision Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Vision Screening Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Primary Vision Care and Related Services . . . . . . . . . . . . . . . . . . . . . . 3
Eye Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Eye Glasses and Corrective Contact Lenses . . . . . . . . . . . . . . . . . . . . . 3
Screening of Vision Disorders among Children . . . . . . . . . . . . . . . . . . . . . . 3
The SCHIP Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Vision-Related Benefits under SCHIP Medicaid Expansion Programs . . . . 6
Medicaid’s EPSDT Service Category . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Vision-Related Benefits under SCHIP Separate State Plans . . . . . . . . . . . . . 9
Scope of Vision-Related Benefits for Children: A Snapshot of Selected
Medicaid and SCHIP Coverage Policies in FY2000 . . . . . . . . . . . . . . . . 11
Survey Design and Data Caveats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
General Coverage Policies and Methods for Limiting Benefits . . . . . . . . . 14
Well-Child (non-EPSDT) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Eye Glasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
The Nature of Benefit Limits for Children under Medicaid
and SCHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
List of Tables
Table 1. Coverage of, and Limits for Monitoring of Well-Child (Non-EPSDT)
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 15
Table 2. Coverage of, and Limits for Monitoring of Physician Services
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 16
Table 3. Coverage of, and Limits for Monitoring of Vision Services
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 18
Table 4. Coverage of, and Limits for Monitoring of Eye Glasses
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 20
Appendix A. Specified Limits and/or Monitoring of Well-Child
(Non-EPSDT) Services for Children under Medicaid and SCHIP
(as of June 2000) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Appendix B. Specified Limits and/or Monitoring of Physician Services
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 28
Appendix C. Specified Limits and/or Monitoring of Vision Services
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 31
Appendix D. Specified Limits and/or Monitoring of Eye Glasses
for Children under Medicaid and SCHIP (as of June 2000) . . . . . . . . . . . . 38

Coverage of Vision Services under the State
Children’s Health Insurance Program
(SCHIP)
Background
According to the American Academy of Pediatrics, in 2002, vision disorders
were the fourth most common disability among children in the United States, and the
leading cause of impaired conditions among children ages 0 through 18. Among
preschool-aged children, as many as 2 to 5% were estimated to have impaired vision.
However, of the estimated 21% of preschool aged children that received vision
screening (i.e., services to detect poor vision or risk factors that interfere with vision
and normal visual development), 14% received a comprehensive vision exam
provided by an optometrist, or ophthalmologist appropriately trained to treat pediatric
patients.1
Young children are particularly vulnerable to conditions that interfere with
vision and visual development. When detected early, many childhood vision
abnormalities are treatable, but the potential for correction that will lead to normal
visual development diminishes with age. Thus, early detection and treatment are
necessary to ensure the best possible outcome. Common vision disorders or
abnormalities in visual development among children include the following:2
! Amblyopia. Amblyopia, or lazy eye, is diminished vision in one eye
resulting from altered visual development where the part of the brain
that controls vision favors one eye over the other. If the weaker eye
is untreated, eyesight will progressively worsen. This disorder is the
most common cause of vision loss in children in the United States,
affecting approximately 5% of the child population.3 Treatment for
amblyopia includes corrective lenses; eye surgery; miotic eye drops;
or other therapies including occlusion (i.e., covering) of the opposite
eye; or optical blurring. Amblyopia is often caused by:
— Strabismus. A misalignment of the eyes resulting in one eye
being used less than the other;
1 Pediatrics, vol. 109, no. 3, Mar. 2002, pp. 524-525.
2 Monte D. Mills, “The Eye in Childhood,” American Academy of Family Physician, Sept.
1, 1999.
3 [http://www.visionchannel.net/amblyopia/]

CRS-2
— Anisometropia. Unequal refractive components of the eye
(e.g., one eye may be nearsighted and the other farsighted). This
disorder results in images that are not focused simultaneously,
so the brain favors the stronger eye;
— Deprivation. Includes vision problems where something
(e.g., cataracts, ptosis, and corneal scars) interferes with equal
visual development in both eyes;
— Accommodating estropia. Excessive reflexive convergence
or cross eyes;
— Nystagmus. Involuntary, rhythmic oscillation of the eyes
caused by bilateral poor vision or abnormal motor input;
— Retinopathy of prematurity (ROP). ROP is a vision disorder
of developing blood vessels that occurs in premature newborns
(i.e., those born at less than 32 weeks);
! Refractive errors. Nearsightedness (myopia), farsightedness
(hyperopia), and astigmatism;
! Ocular Diseases. Such as optic nerve disorders and ocular motility
disorders; and
! Color Vision Defects. Defects in color vision where a person has
difficulty distinguishing between colors that are on the “confusion
lines” (e.g., yellow and blue, or yellow and violet).
Children’s vision screening services to detect such eye problems have long been
a mandated part of several federal health programs including the Early and Periodic
Screening, Diagnosis, and Treatment Program (EPSDT) under Medicaid,4 Head
Start,5 and some of the children’s programs under the Maternal and Child Health
(MCH) block grant.6 Medicaid regulations require state Medicaid agencies to
coordinate child health initiatives (including health screening services) with Title V
(Maternal and Child Health) programs, and with other related programs such as Head
Start. In addition, the Education of the Handicapped Act7 mandates vision screening
for children with disabilities and/or developmental delays that enter early intervention
programs. Early intervention programs provide an array of services and supports for
children with special needs, and for their families.
4 Section 1905(r) of the Social Security Act.
5 U.S. Department of Health and Human Services, Head Start: A Child Development
Program. Washington, DC, Department of Health and Human Services, 1981, DHHS
Publications No. (OHDS) 81-30192.
6 U.S. Department of Health and Human Services, Legislative Base Maternal Child Health
Programs, Washington, DC, Department of Health and Human Services, 1980, DHHS
Publication Number (HSA) 80-5221.
7 20 U.S.C. § 1400.

CRS-3
What Are Vision Services and What Types of Providers
Deliver Vision Services?
To provide context for the discussion that follows, this section describes various
vision services, and the types of providers that generally offer such services.
Vision Screening Services. Vision screening services include procedures
to detect poor vision or risk factors that interfere with vision and normal visual
development. Such services may be provided in a variety of settings (e.g., schools,
health clinics, child care settings, optometrist’s office, etc.), and may be conducted
by a variety of qualified health service providers (e.g., school nurses, parent
volunteers, medical practitioners, optometrists, etc.).
Primary Vision Care and Related Services. Optometrists provide most
primary vision care. Primary vision care includes eye exams to diagnose vision
problems and eye diseases, and to test patients’ visual acuity, depth and color
perception, and ability to focus and coordinate the eyes. In general an optometrist’s
role is to analyze test results and develop a treatment plan. Optometrists prescribe
eyeglasses and contact lenses and provide vision therapy and low-vision
rehabilitation. They are qualified to administer drugs to patients to aid in the
diagnosis of vision problems and to prescribe drugs to treat some eye diseases.
Optometrists often provide preoperative and postoperative care to patients who have
vision correction or other eye surgery. They also diagnose conditions due to systemic
diseases such as diabetes and high blood pressure, referring patients to other health
practitioners as needed.
Ophthalmologists are physicians who specialize in eye care. Like optometrists,
they provide primary vision care services like those listed above; however, in
addition, they diagnose and treat eye diseases, deformities, and injuries that require
surgery.
Eye Surgery. Eye surgery includes procedures performed by ophthalmologists
to correct physical deformities, or to repair tissue after injuries, or preventive
surgeries on patients with debilitating diseases or disorders.
Eye Glasses and Corrective Contact Lenses. Eyeglasses and contact
lenses are aids to vision prescribed by a physician skilled in diseases of the eye or by
an optometrist. Opticians fit eye glasses and, in some states, may fit contact lenses
according to prescriptions written by ophthalmologists or optometrists. Some
opticians specialize in fitting contacts, artificial eyes, or cosmetic shells to cover
blemished eyes.
Screening of Vision Disorders among Children
Despite the prevalence of vision disorders among children, vision screening
programs to detect poor vision or risk factors that interfere with vision and normal

CRS-4
visual development vary by state and by geographic region.8 A 1999 vision screening
policies and procedures survey among the 50 states and the District of Columbia
showed that 34 states had guidelines for pre-school age vision screening, even though
consensus among vision care experts recommends that eye screenings occur as early
as childbirth. Two additional states (i.e., Virginia, and Washington) had preschool
vision screening guidelines, but only for children with disabilities. Further, in most
states, mandatory vision screening did not occur until the children entered
kindergarten. The survey also indicated that there was little consensus across states
on the ages at which children should be screened, the areas of vision that should be
evaluated, the appropriate tests to administer, or the types of personnel that should
administer the screening (e.g., school nurses, aides, teachers, volunteer parent
assistants, medical practitioners, trained technicians, etc.). The authors concluded
that even among states with well-established vision screening policies, there is no
guarantee that the procedures in place would effectively identify children who require
further examination by a trained eye care specialist (i.e., optometrist, or
ophthalmologist).9
In April 2003, four professional organizations10 concerned with children’s eye
care developed guidelines to be used by physicians, nurses, educational institutions,
public health departments, and other professionals who perform vision screening
services for infants, children, and young adults. The guidelines establish that eye
examinations and vision screening should be performed on newborns at birth, and at
all well-child visits. In addition, visual acuity measurement tests (e.g., picture tests,
Snellen numbers, or the tumbling E test) should be performed as early as possible,
usually at 3 years of age. The guidelines also establish criteria for appropriate
number, timing, and age-appropriate procedures for each eye evaluation. Finally, the
guidelines recommend that children found to have an ocular abnormality or who fail
vision screening should be referred to a pediatric ophthalmologist or an eye care
specialist appropriately trained to treat pediatric patients.11
Many of the public health programs listed above (e.g., Head Start, Medicaid’s
EPSDT program, and MCH) with mandatory vision screening requirements rely
instead on the Recommendations for Preventive Pediatric Health Care periodicity
schedules developed by the Committee on Practice and Ambulatory Medicine of the
American Academy of Pediatrics (AAP) to establish vision screening guidelines for
their program enrollees.12 As compared to the 2003 vision screening standards
8 [http://www.medicalhomeinfo.org/screening/Screen%20Materials/PUPVS_%7E2.DOC].
9 Johanna Seddon and Donald Fong, eds. Public Health and the Eye: A Survey of Vision
Screening Policy of Preschool Children in the United States, Survey of Ophthalmology,
vol., no. 5, Mar.-Apr. 1999.
10 The four eye care professional organizations include (1) the American Academy of
Pediatrics (AAP), (2) the American Association of Certified Orthoptists, (3) the American
Association for Pediatric Ophthalmology and Strabismus, and (4) the American Academy
of Ophthalmology.
11 Pediatrics, vol. 111, no. 4, Apr. 2003.
12 Centers for Medicare and Medicaid Services (CMS), State Medicaid Manual, Part 5,
(continued...)

CRS-5
mentioned above, the AAP’s recommendations are far less detailed in that they do
not identify specific age-appropriate procedures for each eye evaluation, or the level
of training required by individuals who perform the screenings. Instead, they indicate
ages for which vision screening should be performed either subjectively based on the
child’s medical history, or objectively based on a standard testing method.
The SCHIP Program
Background
SCHIP was established in 1997 under a new Title XXI of the Social Security
Act, and provides health insurance to certain uninsured children in families with
modest income. A total of $39.7 billion has been appropriated for SCHIP for
FY1998 through FY2007. Approximately, 5.8 million children were enrolled in
SCHIP during FY2003. Nationally, through FY2003, $13.7 billion in federal dollars
had been spent under the program.
In general, Title XXI defines a targeted low-income child as one who is under
the age of 19 years with no health insurance, and who would not have been eligible
for Medicaid under the rules in effect in the state on March 31, 1997. States may set
the upper income level for targeted low-income children up to 200% of the federal
poverty level (FPL),13 or if the applicable Medicaid income level for children is at or
above 200% FPL prior to SCHIP, the upper income limit may be raised an additional
50 percentage points above that level. As of FY2002, the upper income eligibility
limit under SCHIP had reached 350% FPL (in New Jersey). Nearly one-half (24) of
the states and the District of Columbia had established upper income limits at 200%
FPL. Another 13 states exceeded 200% FPL. The remaining 13 states set maximum
income limits below 200% FPL.
Within these general rules, states may provide child health assistance to
qualifying children in two basic ways. They may cover children under their Medicaid
programs, and/or they may create a separate SCHIP program. (More details on
available benefits under each approach are described in the next section.) When
states provide Medicaid coverage to targeted low-income children, Medicaid rules
typically apply. When states provide coverage to targeted low-income children
through separate SCHIP programs, Title XXI rules typically apply. In both cases, the
federal share of program costs comes from federal SCHIP appropriations. As of July
2004, 17 states had Medicaid expansions, 18 had separate state programs, and 21
used a combination approach.14
12 (...continued)
Early, Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Section 5360, pp.
5-57. Available on CMS’s website at [http://www.cms.hhs.gov/manuals/pub45/pub_45.asp].
13 In 2002, the poverty guideline in the 48 contiguous states and D.C. was $18,850 for a
family of four. Information available at [http://aspe.hhs.gov/poverty/04poverty.shtml].
14 Some states classified as “separate state program states” have more than one such
program. Program totals include the outlying areas.

CRS-6
Title XXI does not establish an individual entitlement to benefits. Instead, Title
XXI entitles states with approved state plans for Medicaid coverage or separate
SCHIP programs to predetermined federal allotments based on a distribution formula
set in the law. However, targeted low-income children covered under Medicaid are
entitled to the benefits offered under that program as dictated by Medicaid law. No
such individual entitlement exists for targeted low-income children covered in
separate SCHIP programs.
Vision-Related Benefits under SCHIP Medicaid Expansion
Programs
Under Medicaid (including SCHIP Medicaid expansion programs), some
benefits are mandatory and others may be covered at state option. States that choose
to expand Medicaid to new eligibles under SCHIP authority must provide the full
range of mandatory Medicaid benefits for the categorically needy, as well as all
optional services covered.15
Some categories of service have an obvious connection to vision screening,
while others do not. This is in part due to the fact that many of the benefit categories
listed in statute identify a type of provider or care setting rather than a type of service.
For example, as discussed above, a wide variety of qualified providers may deliver
vision screening services under Medicaid, including physicians, optometrists, and
other qualified providers, and enrollees may access vision-related services in a
variety of settings such as a hospital or a rural health clinic. The Medicaid
mandatory categories of service that all states must offer to their categorically needy
groups, and that are likely to include vision-related benefits such as vision
screenings, eye exams, and treatment of eye diseases or visual impairments (e.g., eye
surgery or eye glasses), are:
! inpatient hospital services;
! outpatient hospital services;
15 The two broad eligibility categories described in Medicaid statute include categorically
needy and medically needy. Categorically needy refers to low-income families and children,
aged, or individuals who are blind or have a disability, and certain pregnant women who are
eligible for Medicaid. Medically needy individuals are persons who fall into one of the
categorically needy groups but whose income and resources are too high to qualify as
categorically needy. (42 C.F.R. §435.4).
Special benefits rules apply if states choose to cover medically needy populations.
States may offer a more restricted benefit package for those enrollees but are required, at a
minimum, to offer the following: prenatal and delivery services for pregnant women;
ambulatory services for individuals under 18 and those entitled to institutional services; and
home health services for individuals entitled to nursing facility services. Broader
requirements apply if a state has chosen to provide coverage for medically needy persons
in institutions for mental disease and intermediate care facilities for the mentally retarded.
If so, the state is required to cover either all of the mandatory services, or alternatively, the
optional services listed in any seven of the categories of care and services in Medicaid law
defining covered benefits.

CRS-7
! physician services (e.g., including optometrists);16
! rural health clinic services;
! federally qualified health center services;
! other laboratory and X-ray services (e.g., opthalmoscopy to view and
analyze diseases of the optic nerve);
! certified pediatric and family nurse practitioners; and
! early and periodic screening, diagnosis and treatment (EPSDT) for
persons under age 21 years (more on this benefit below).
Categories of optional benefits that can include vision care are:
! eye glasses;
! clinic services;
! certain diagnostic, screening, preventive, and rehabilitative services;
! certain nurse practitioner services;
! certain targeted case management services; and
! prescription drugs.
Finally, under Medicaid, states can apply for waivers to modify virtually all
aspects of their programs without congressional review. Under the Section 1115
waiver authority, states may test a major restructuring of their Medicaid program.
States have the flexibility to experiment with different approaches for the delivery
of health care services, or to adapt their programs to the special needs of particular
geographic areas or groups of recipients. As of the fall of 2003, there were 53
operational Medicaid Section 1115 waiver programs in 32 states and the District of
Columbia. While none of these waivers specifically focus on vision-related benefits,
some provide access to such services through redefined benefit packages, and/or
provide vision-related services for population groups that would not otherwise be
covered such as parents and childless adults.
Medicaid’s EPSDT Service Category. Coverage policies and benefit
limits for children under Medicaid are seldom absolute in part because of special
provisions in the law requiring that children receive all medically necessary services
authorized in federal statute through the EPSDT program. The EPSDT program
provides screening and preventive care to nearly all groups of Medicaid beneficiaries
under 21 years of age.17 Furthermore, under EPSDT, states are required to provide
all federally-allowed treatment to correct problems identified through screenings,
even if the specific treatment needed is not otherwise covered under a state’s
Medicaid plan.18 Thus, states may be required to cover some services for children
that would be optional or not covered at all for adults. This guarantee does not exist
in SCHIP. Instead, SCHIP children have access to benefit packages modeled after
16 A doctor of optometry, though not an M.D., is considered a “physician” for all the covered
vision care services he/she is legally authorized to perform in the state in which he/she
performs them. (Social Security Act §1861(r), and 42 C.F.R. § 410.20(b)).
17 EPSDT is not a mandatory benefit for the medically needy, although states that choose to
extend EPSDT to their medically needy population must make the benefit available to all
individuals under age 21.
18 Social Security Act §1905(r).

CRS-8
private sector, commercial insurance products. Under commercial insurance
products, benefits are always limited by medical necessity, but other limits defining
coverage may exist as well.
At a minimum, vision screening services under EPSDT must include diagnosis
and treatment for defects in vision and must cover eyeglasses. States set distinct
standards and protocols for each component of the EPSDT services, including vision
screenings.19 State-specific periodicity schedules to determine the type of procedure
to use, and the criteria for determining when a child should be referred for further
diagnostic examination must meet reasonable standards of medical practice
established by the state after consultation with recognized pediatric medical
organizations. Unlike state periodicity schedules for general medical screening
services, the Centers for Medicare and Medicaid Services (CMS) does not require
states to submit their vision care periodicity schedules as a part of their Medicaid
state plan for approval by CMS. However, most states’ vision care periodicity
schedules are in accordance with the recommendations of the American Academy of
Pediatrics (AAP).20
The State Medicaid Manual explains that EPSDT exams must be performed by,
or under the supervision of, a certified Medicaid physician, dentist, or other provider
qualified under state law to furnish primary medical and health services. EPSDT
screening services may be provided in several settings including state and local health
departments; school health programs; programs for children with special health
needs; Maternity and Infant Care projects; children and youth programs; Head Start
programs; community health centers; well-child and rural health clinics;
medical/dental schools; prepaid health care plans; developmental disability agencies;
university-affiliated facilities; day care centers; rehabilitation agencies and voluntary
health organizations. EPSDT qualified providers may include nurse practitioners,
nurse midwives, registered nurses, physician assistants, private practitioners, and/or
any other licensed practitioners. With such a broad range of service delivery settings
and qualified provider arrangements, tracking operational vision screening practices
under the EPSDT requirement within a state is complex.
EPSDT Program Data. States must submit an annual EPSDT report (i.e.,
CMS Form 416) to CMS with basic program participation information. The current
CMS Form 416 records the number of children by age group (i.e., less than 1 year
old, 1-2 years of age, 3-5 years of age, 6-9 years of age, 10-14 years of age, 15-18
years of age, and 19-20 years of age) and by basis of Medicaid eligibility (i.e.,
categorically needy, or medically needy) who:
19 Section 1905(r) of the Social Security Act specifies that each state must develop its own
periodicity schedule for screening, vision, hearing and dental services after appropriate
consultation with medical and dental organizations involved in child health care. By law,
the CMS may not require states to use any particular periodicity schedule for the delivery
of EPSDT services under Medicaid. (For more details, see CMS, State Medicaid Manual:
Part 5: Early and Periodic Screening Diagnostic and Treatment Services, Section 5124, pp.
5-19.)
20 Personal communication with Cindy Ross, CMS, May 3, 2004.

CRS-9
! are eligible for EPSDT services;
! have received child health screening services;
! are referred for corrective treatment;
! have received dental services;
! are enrolled in managed care; and/or
! are screened for blood lead tests.
For purposes of reporting on this form, child health screening services are
defined as initial or periodic screens according to a state’s screening periodicity
schedule. States are instructed to report children who received a full medical screen
including a comprehensive health and developmental history; a comprehensive
unclothed physical exam; immunizations, when appropriate; laboratory tests,
including lead testing, when appropriate; and health education and anticipatory
guidance. On the current CMS Form 416, children receiving only vision screening
services and/or hearing screening services are not counted as having received a
medical screen.
Prior to FY1999, the CMS Form 416 also tracked the number of children who
received vision screens, and/or hearing screens. FY1998 was the last year vision
screening data were available from the CMS Form 416, and the last year for which
CMS 416 data are available for all 50 states and the District of Columbia. In
FY1998, 21.7 million children were eligible for the EPSDT program. Of those
eligible children, 3.1 million (14.2%) received a vision screen. In that year, children
age 6 through 14 were among those most likely to receive a vision screen.21 These
data should be interpreted with caution, however, because as discussed above there
are several other Medicaid benefit categories (e.g., rural health clinic services and
physician services) where vision screening services may have been rendered.
Vision-Related Benefits under SCHIP Separate State Plans
The SCHIP statute defines child health assistance to include a wide range of
coverable benefits. As with Medicaid, some categories of service have an obvious
connection to vision-related benefits while others do not. The categories of service
that may include vision screening and corrective eye treatment are:
! inpatient hospital services;
! outpatient hospital services;
! physician services;
! surgical services;
! clinic services (including health center services) and other
ambulatory health care services;
! prescription drugs and biologicals and the administration of such
drugs and biologicals;
! over-the-counter medications;
! laboratory and radiological services;
21 CMS Form 416, Annual EPSDT Participation Report, All States, FY1998, available at
[http://www.cms.hhs.gov/medicaid/epsdt/ep1998n.pdf]

CRS-10
! durable medical equipment and other medically-related or remedial
devices (such as prosthetic devices, implants, eye glasses, and
adaptive devices);
! nursing care services (such as nurse practitioner services, nurse
midwife services, advanced practice nurse services, private duty
nursing care, pediatric nurse services, and respiratory care services)
in a home, school, or other setting;
! any other medical, diagnostic, screening, preventive, restorative,
remedial, therapeutic, or rehabilitative services (if recognized by
state law, and prescribed, furnished or supervised by a physician or
other licensed practitioner or state- or local-government operated
health care facility); and
! any other health care services or items specified by the Secretary and
not excluded under this section.
Under SCHIP separate state programs, states do not simply select among these
benefits in establishing what is and is not covered. Rather, states choose from any
of three benefit options: (1) a benchmark benefit package, (2) benchmark equivalent
coverage, or (3) any other benefits plan that the Secretary of Health and Human
Services determines will provide appropriate coverage to beneficiaries. The option
chosen determines the set of covered benefits under separate SCHIP programs.
A benchmark benefit package is one of the following three plans: (1) the
standard Blue Cross/Blue Shield preferred provider option offered under the Federal
Employees Health Benefits Program (FEHBP); (2) the health coverage that is offered
and generally available to state employees in the state involved; and (3) the health
coverage that is offered by a health maintenance organization (HMO) with the largest
commercial (non-Medicaid) enrollment in the state involved.
Benchmark equivalent coverage is defined as a package of benefits that has the
same actuarial value as one of the benchmark benefit packages. A state choosing to
provide benchmark equivalent coverage must cover each of the benefits in the “basic
benefits category.” The benefits in the basic benefits category are inpatient and
outpatient hospital services, physicians’ surgical and medical services, lab and x-ray
services, and well-baby and well-child care (more discussion on this requirement
below), including age-appropriate immunizations.22 Benchmark equivalent coverage
must also include at least 75% of the actuarial value of coverage under the
benchmark plan for each of the benefits in the “additional service category.” These
additional services include prescription drugs, mental health services, vision services,
and hearing services.23
SCHIP regulations define well-baby and well-child services as: (1) healthy
newborn inpatient physician visits, including routine screening including vision
screenings (whether provided on an inpatient or on an outpatient basis); (2) routine
physical examinations; (3) laboratory tests relating to their visits; (4) immunizations,
and related office visits; and (5) when covered under the state plan (at the state’s
22 Social Security Act § 2103(c)(1).
23 Social Security Act § 2103(a)(2)(C).

CRS-11
option) routine preventive and diagnostic dental services.24 As with Medicaid, CMS
does not require states to submit their well-baby and well-child or vision screening
periodicity schedules as a part of their SCHIP state plan, nor (except in the case of
immunizations) has CMS endorsed a specific professional standard (i.e., periodicity
schedule) for well-baby and well-child care coverage under SCHIP plans. Apart
from immunizations and dental services, CMS allows states to define well-baby and
well-child care for coverage purposes.
Finally, as with Medicaid, states may apply for Section 1115 waivers to modify
program rules that establish special programs or demonstration projects to
accommodate unique needs. Currently, 12 states have such waivers under SCHIP.
While none of these waivers specifically focus on vision-related services, like some
of the Medicaid Section 1115 waiver programs, they may provide access to such
services through redefined benefit packages, and/or provide vision-related services
for population groups that would not otherwise be covered.
Scope of Vision-Related Benefits for Children:
A Snapshot of Selected Medicaid and SCHIP
Coverage Policies in FY2000
Survey Design and Data Caveats
In 2000, the Congressional Research Service (CRS) contracted with the National
Academy for State Health Policy (NASHP) to collect data from Medicaid and SCHIP
state agencies on limits placed on selected benefits for children under each program.
Two parallel survey instruments25 were developed with extensive input from state
officials; one for Medicaid programs and one for separate state SCHIP programs.
The benefits data collected from these surveys represent general program policies as
of June 2000.
For each benefit category listed on the survey, respondents indicated the amount
of each service children could receive without special permission, that is, before prior
authorization26 was required. If there was no point at which prior authorization for
24 42 C.F.R. § 457.520.
25 These surveys covered other topics in addition to benefits for children. In the Medicaid
survey, detailed data were also collected on eligibility rules and the extent and scope of
managed care activities for all Medicaid populations. The SCHIP survey covered many
other major aspects of program policy (e.g., eligibility rules, administrative services,
outreach activities, employer-sponsored insurance, healthcare marketplace, public input
methods, coordination with other state agencies, managed care policies, cost-sharing, and
crowd-out prevention). For information on results from these other survey components, go
to [http://www.nashp.org].
26 Prior authorization, also referred to as precertification or preadmission screening, means
that an entity other than a provider (e.g., state Medicaid agency, fiscal agent, or other
contractor) must approve the delivery of a specific service to a specific beneficiary or the
(continued...)

CRS-12
continued services was necessary, the benefit was identified as unlimited. State
officials could also indicate that limits for a specific benefit were absolute, meaning
that children could not receive more than the specified amounts even with prior
authorization.
For Medicaid, including Medicaid expansion programs under SCHIP, survey
results were reported for all 50 states and the District of Columbia. For SCHIP,
survey results were reported for a total of 41 separate programs in 33 states,
representing the universe of such states and programs in June 2000. Two states
(California and New Jersey) had two SCHIP programs with different benefit plans,
and three states (Connecticut, Florida, and Massachusetts) each had three SCHIP
programs with different benefit plans.
Four service categories, all of which could include vision-related benefits such
as vision screenings, eye exams, treatment of eye diseases or visual impairments
(e.g., eye surgery or eye glasses) were included. These were well-child care (non-
EPSDT), physician services (SCHIP survey only),27 vision services, and eye glasses.
There is no direct one-to-one correspondence between any one of the four
service categories included on the surveys and a single coverable benefit listed in
Medicaid statute. Vision screening services for children under Medicaid typically
occur as a part of a well-child visit under the category of service called “diagnostic,
screening, preventive, and rehabilitative services,” or under the EPSDT benefit.28 In
addition, vision screening services rendered to a child are not always identifiable in
Medicaid claims-level data as they are often billed as a part of other well-care
screening service visits.29 Comprehensive vision exams (i.e., exams provided by an
ophthalmologist or an eye care specialist appropriately trained to treat pediatric
patients) are generally covered under the physician services category, but may also
be covered under other service categories such as EPSDT, or under the optional
benefit listed above called diagnostic, screening, preventive, and rehabilitative
services. Eye surgery and prescription drugs to treat eye diseases may be covered
under physician services, pharmacy, or outpatient hospital services. Finally,
26 (...continued)
Medicaid agency will not reimburse the provider for that service. Examples of other
common utilization controls include (1) concurrent review, which means an authorized
entity (e.g., state Medicaid agency, or a contractor) reviews services while they are being
provided to a given beneficiary; for example, hospital stays may be subject to concurrent
review when they exceed a specified length of stay, and (2) utilization review, which is a
generic term encompassing all reviews of service provision — whether they happen
prospectively, concurrently, or retrospectively.
27 The amount, duration, and scope of physician services was not captured on the Medicaid
portion of the benefits survey because coverage of physician services is mandatory under
Medicaid. When medically necessary for children, all benefits (mandatory or optional) are
essentially unlimited due to EPSDT.
28 Personal communication with Cindy Ruff, CMS, May 4, 2004.
29 The state Medicaid manual does not require states to break out vision services from other
screening services under EPSDT. Also as discussed above, the CMS Form 416 no longer
captures vision screening services separately from other screening services.

CRS-13
eyeglasses, and other aids to vision prescribed by a physician skilled in diseases of
the eye or an optometrist are often covered under Medicaid’s eye glasses service
category or EPSDT, but may be covered under a different benefit category
depending on the state.
Like Medicaid, SCHIP has more than one benefit category listed in statute that
would encompass vision screening services. Several could apply here (e.g., physician
services, clinic services and other ambulatory health care services, and any other
medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or
rehabilitative services).
In sum, each of the four categories of service used in the surveys likely
corresponds to multiple benefits listed in both Medicaid and SCHIP statute. This is
an important problem for the survey design because very different limits may apply
to “vision screening services,” as included on the surveys, when delivered as a
“physician service” versus a “medical, diagnostic, screening, preventive, restorative,
remedial, therapeutic, or rehabilitative service,” for example. For this reason, the
survey data are imprecise.
To further complicate the picture, both Medicaid and SCHIP programs rely on
managed care organizations (MCOs) to deliver services to most beneficiaries,
especially for children without disabilities.30 There are likely to be variations in
coverage of, and limits placed on, specific benefits across Medicaid and/or SCHIP
managed care plans in a given state. Detailed data on variations in benefit limits
specific to individual managed care contracts under each state program, which can
differ from the general criteria delineated in SCHIP state plans as reported here, were
not captured.
Also, these data date from 2000. While these survey data serve as a baseline
documenting general coverage policies in place during a strong economic period
when many states were expanding their Medicaid and SCHIP programs, states may
have changed coverage policies since that time.31 The results from the two surveys
represent general, statewide benefit limit policies for broad classifications of vision-
related services for children under each program. The importance of these survey
30 Under SCHIP, managed care is the predominant service delivery system. At the time of
the CRS-sponsored survey (June 2000), all but five SCHIP programs (AL, NC, ND, WV,
and WY) contracted with one or more managed care plans to deliver care to SCHIP children.
CA, for example, contracted with 23 comprehensive health plans.
31 Faced with declining state revenues and increasing medical care expenses, states
implemented a number of cost containment strategies for fiscal years 2003 and 2004.
According to the National Association of State Budget Officers, Medicaid and Other State
Healthcare Issues: Current Trends, June 2003, a majority of the Medicaid cutbacks focused
on containing prescription drug costs, reducing provider reimbursement rates, and
eliminating or reducing optional services and populations (e.g., eliminating coverage for
certain qualified alien children, and eliminating optional services such as dental, optometry,
and podiatry services). Under SCHIP, about one third of states implemented cost
containment measures in FY2003 or planned to do so in FY2004. Examples of such
containment strategies include capping program enrollment, increasing beneficiary cost-
sharing requirements, and reducing provider payment rates.

CRS-14
results lies in the identification of the different methods states use in their Medicaid
versus SCHIP programs to define the breadth of these services for children.
General Coverage Policies and Methods for Limiting Benefits
For each of the four vision-related benefit categories included in the CRS-
sponsored surveys, Tables 1 through 4 provide a summary of whether the service
is covered, and general information about service limits and monitoring activities for
Medicaid and separate SCHIP programs across states. The general coverage policies
and methods for limiting benefits are summarized below. Appendices A through
D provide information on the specific limits and monitoring activities identified by
states for their Medicaid and SCHIP programs (when applicable) as of June 2000.
Well-Child (non-EPSDT) Services. As of June 2000, 11 out of 51
Medicaid programs did not cover well-child services outside of EPSDT. By contrast,
all 33 states covered well-child services for children in at least one of their SCHIP
programs (only Connecticut-B and Connecticut-C did not cover this benefit under
SCHIP).32 This difference is likely due to the fact that under Medicaid, states cover
well-child care and screening services under the mandatory EPSDT benefit instead.
Under Medicaid, and SCHIP, approximately two-thirds of the programs reported that
well-child care services for children were unlimited (see Table 1).
Under SCHIP, of the eight programs with specified limits and/or monitoring of
well-child services, three programs (Arizona, California-A, and California-B)
reported that the amount, duration, and scope of those services varies by MCO. Four
of the five remaining programs (Alabama, North Carolina, North Dakota, and West
Virginia) reported that the well-child visits follow AAP guidelines, and/or the state-
specific periodicity schedule. Under four SCHIP programs (Connecticut-A, Indiana,
Mississippi, and New York), well-child quantity limits were not specified (see
Appendix A).
32 The state’s separate child health program (CT-B) covers uninsured children whose family
income is at or below 300 % of the federal poverty level. Children with special needs who
are eligible for the wrap-around services offered in (CT-C) receive medically necessary
services under (CT-A).

CRS-15
Table 1. Coverage of, and Limits for Monitoring of Well-Child
(Non-EPSDT) for Children under Medicaid and SCHIP
(as of June 2000)
Medicaid (51 programs in 50
states and DC)
SCHIP
Program classifications
CN only
CN + MN
(41 programs in 33 states)
Programs that do not cover
NOTE: Under Medicaid, all
2 — CT-B, and CT-C
well-child (non-EPSDT)
states cover well-child care and
services
screening services under the
mandatory EPSDT benefit. The
states listed below chose not to
cover well-child care and
screening services outside of
EPSDT as well.
3 — AL, MS,
8 — FL, LA,
and WY
MA, NC, OK,
TX, VA, and
WA
Programs with unlimited
10 — AK,
24 — AR, CA,
27 — CO, DE, FL-A, FL-B,
well-child (non-EPSDT)
CO, DE, IN,
CT, DC, GA,
FL-C, IA, IL, KS, KY, MA-
services
MO, NM,
HI, IA, KS,
A, MA-B, MA-C, ME, MI,
NV, OR, SC,
KY, MD, ME,
MT, NH, NJ-A, NJ-B, NV,
and SD
MI, MN, MT,
OR, PA, TX, UT, VA, VT,
ND, NE, NH,
WA, and WY
NJ, NY, PA,
RI, VT, WI,
and WV
Programs with specified
3 — AZ, ID,
3 — IL, TN,
8 — AL, AZ, CA-A, CA-B,
limits and/or monitoring of
and OH
and UT
GA, NC, ND, and WV
well-child (non-EPSDT)
services
Programs for which limits
0
0
4 — CT-A, IN, MS, and
were not specified
NY
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS.
Notes: State abbreviations are used in this table. In the Medicaid column, the subcolumn labeled “CN
only”means that coverage, limitations and monitoring of vision services apply only to beneficiaries
classified as categorically needy, and the subcolumn labeled “CN+MN” means that coverage,
limitations and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups under
Medicaid. These 36 states may be shown in either the “CN only” or the “CN+MN” subcolumns,
depending on benefit coverage policies for categorically needy versus medically needy beneficiaries.
Those states without medically needy programs were Arkansas, Alabama, Arizona, Colorado,
Delaware, Idaho, Indiana, Missouri, Mississippi, New Mexico, Nevada, Ohio, South Carolina, South
Dakota, and Wyoming. These 15 states are always listed in the “CN only” subcolumn. In the SCHIP
column, 28 states had a single separate SCHIP program represented by the state abbreviation. The
remaining five states with separate SCHIP programs each had more than one such program with

CRS-16
different benefit plans. Two states (California and New Jersey) each had two separate SCHIP
programs. In this case, an A or B extension was added to the state abbreviation to distinguish these
programs (e.g., California-A, California-B). Three states (Connecticut, Florida, and Massachusetts)
each had three separate SCHIP programs. In this case, an A, B, or C extension was added to the state
abbreviation to distinguish these multiple programs (e.g., Connecticut-A, Connecticut-B, Connecticut-
C).
Physician Services. States were not required to report the amount, duration,
and scope of physician services on the Medicaid benefits survey because coverage
of physician services is mandatory under Medicaid. When medically necessary for
children, all benefits (mandatory or optional) are essentially unlimited due to EPSDT.
Under SCHIP, most programs (40 of 41 programs) covered physician services for
children (see Table 2).33 States were not required to report quantity limits for
physician services as the types of physicians covered under this benefit are diverse
(e.g., dentists, ophthalmologists, and various physician specialists), and SCHIP
programs generally allow for coverage that is within the scope of practice within each
given discipline (see Appendix B).
Table 2. Coverage of, and Limits for Monitoring of Physician
Services for Children under Medicaid and SCHIP
(as of June 2000)
Medicaid (51 programs in
SCHIP (41 programs
Program classifications
50 states and DC)
in 33 states)
Programs that do not cover
Service not included in the
1 — CT-C*
physician services
Medicaid survey (see note)
Programs with unlimited
0
physician services
Programs with specified limits
0
and/or monitoring of physician
services
Programs for which limits
States were not required to
were not specified
report quantity limits for
physician services (see note)
40 — AL, AZ, CA-A, CA-B,
CO, CT-A, CT-B, DE, FL-A,
FL-B, FL-C, GA, IA, IL, IN,
KS, KY, MA-A, MA-B, MA-C,
ME, MI, MS, MT, NC, ND, NJ-
A, NJ-B**, NH, NV, NY, OR,
PA, TX, UT, VA, VT, WA, WV,
and WY
33 The survey data indicated that NJ-B’s separate state program did not cover physician
services, however conversations with individuals responsible for administering the CRS-
sponsored benefit survey at the National Academy for State Health Policy agreed that this
survey response was likely a result of reporting error. NJ’s separate state program, NJ-B,
offers FEHBP-equivalent coverage, and physician services are included in the FEHBP
benefit package.

CRS-17
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs
and the other for separate state SCHIP programs, conducted by the National Academy for State Health
Policy under contract to CRS.
Notes: The amount, duration, and scope of physician services was not captured on the Medicaid
benefits survey because coverage of physician services is mandatory under Medicaid. When medically
necessary for children, all benefits (mandatory or optional) are essentially unlimited due to EPSDT.
On the SCHIP benefits survey, states were only asked to report covered/not covered for their coverage
of physician services. States were not required to report quantity limits for physician services as the
types of physicians covered under this benefit are diverse (e.g., dentists, ophthalmologists, and general
practitioners), and the programs generally allow for coverage that is within the scope of practice within
each given discipline. In the SCHIP column, 28 states had a single separate SCHIP program
represented by the state abbreviation. The remaining five states with separate SCHIP programs each
had more than one such program with different benefit plans. Two states (California and New Jersey)
each had two separate SCHIP programs. In this case, an A or B extension was added to the state
abbreviation to distinguish these programs (e.g., California-A, California-B). Three states
(Connecticut, Florida, and Massachusetts) each had three separate SCHIP programs. In this case, an
A, B, or C extension was added to the state abbreviation to distinguish these multiple programs (e.g.,
Connecticut-A, Connecticut-B, Connecticut-C).
* The Connecticut-C benefit package provides additional “wrap around” services for children with
special health care needs. Children who are eligible for (Connecticut-C) receive medically
necessary services under (Connecticut-A).
** See footnote number 33.
Vision Services. As of June 2000, all Medicaid programs covered vision
services for children as did nearly all SCHIP programs (except California-B,
Connecticut-B, Connecticut-C, and Michigan). More Medicaid than SCHIP
programs reported that vision services for children were unlimited (39% as compared
to 32%). Fifty-one percent of Medicaid programs reported specified limits and/or
monitoring of their vision services coverage, compared to 46% of SCHIP programs.
Under both Medicaid and SCHIP, there were five programs where vision services
limits existed, but were not specified (see Table 3).
For this survey item, states reported quantity limits for all types of vision-related
services including eye glasses, frames, and contact lenses; vision screenings; eye
exams; and orthopic training. With respect to specified limits on vision services
under Medicaid, four programs (Maine, Minnesota, New Jersey, and Wisconsin)
reported using prior authorization as their only method of limiting access to service
use. One additional program (New York) specified further quantity limits (i.e., one
visit every two years) in addition to their prior authorization requirement. A majority
of the Medicaid programs (26 of 51 programs) reported a specific quantity limit such
as: “one exam every two years,” or “two exams plus follow up without prior
authorization.” In some cases quantity limits were specified for more than one type
of vision-related service (e.g., eye exams and prescription lenses). Four Medicaid
programs (Hawaii, New Mexico, Oklahoma, and Pennsylvania) referred to a vision
screening periodicity schedule — in three cases their EPSDT periodicity schedule —
to identify limits on their vision-related benefits. Finally, in three Medicaid programs
(Arizona, Delaware, and Tennessee), the states reported provider limitations for their
vision-related benefits (i.e., the service coverage varies by MCO).

CRS-18
Under SCHIP, many states reported quantity limits in their separate state
programs for all types of vision-related services including eye glasses, frames, and
contact lenses; vision screenings; and eye exams. In general, the types of quantity
limits placed on vision-related services under SCHIP were similar to those under
Medicaid. In almost half the programs, (19 of 41 programs), states reported a
specific quantity limit such as “one exam per calendar year,” or “refractions limited
to one per year.” Several programs (California-A, Iowa, and Massachusetts-B)
reported that their coverage of vision-related services varies by MCO. In one
program (Utah), the state limited its vision-related benefit to a dollar-based limit, and
in one program (Maine) prior authorization was required to access services. Unlike
under Medicaid, states did not report vision-related periodicity schedules as limits for
their vision service coverage (see Appendix C).
Table 3. Coverage of, and Limits for Monitoring of, Vision
Services for Children under Medicaid and SCHIP
(as of June 2000)
Medicaid (51 programs in 50
states and DC)
SCHIP (41 programs in 33
Program classifications
CN only
CN + MN
states)
Programs that do not cover
0
0
4 — CA-B, CT-B, CT-C, and
vision services
MI
Programs with unlimited
7 — AK, CO,
13 — CA, CT,
13 — CO, DE, FL-A, FL-B,
vision services
NV, OR, RI,
DC, FL, IL, KS,
FL-C, IL, KS, KY, MA-A,
SD, and WY
LA, MI, TX,
MA-C, MT, NV, and WY
UT, VT, WA,
and WV
Programs with specified
9 — AL, DE,
17 — AR, GA,
19 — AL, AZ, CA-A, GA, IA,
limits and/or monitoring of
ID, IN, MO,
HI, IA, KY,
ME, NC, ND, NH, NJ-A, NJ-
vision services
MS, NM, OH,
MD, ME, MT,
B, OR, PA, TX, UT, VA, VT,
and SC
NC, ND, NE,
WA, and WV
NH, NY, OK,
PA, VA, and
WI
Programs for which limits
1 — AZ
4 — MA, MN,
5 — CT-A, IN, MA-B, MS,
were not specified
NJ, and TN
and NY
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs
and the other for separate state SCHIP programs, conducted by the National Academy for State Health
Policy under contract to CRS.
Notes: State abbreviations are used in this table. In the Medicaid column, the subcolumn labeled “CN
only” means that coverage, limitations, and monitoring of vision services apply only to beneficiaries
classified as categorically needy, and the subcolumn labeled “CN+MN” means that coverage,
limitations, and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the “CN + MN”
subcolumns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states without medically needy programs were Alaska, Alabama, Arizona,

CRS-19
Colorado, Delaware, Idaho, Indiana, Missouri, Mississippi, New Mexico, Nevada, Ohio, South
Carolina, South Dakota, and Wyoming. These 15 states are always listed in the “CN Only”
subcolumn.
In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one such
program with different benefit plans. Two states (California and New Jersey) each had two separate
SCHIP programs. In this case, an A or B extension was added to the state abbreviation to distinguish
these programs (e.g., California-A, California-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension was
added to the state abbreviation to distinguish these multiple programs (e.g., Connecticut-A,
Connecticut-B, Connecticut-C).
Eye Glasses. As of June 2000, only one Medicaid program (Delaware) did
not cover eye glasses for their beneficiaries; however, this program is required to
provide coverage of eye glasses under their EPSDT benefit. By contrast, six SCHIP
programs (Calfornia-B, Connecticut-B, Connecticut-C, Florida-B, New York, and
Utah) did not cover eye glasses. Roughly 26% of Medicaid and 22% of SCHIP
programs indicated that their eye glasses benefit was unlimited. An additional 69%
of Medicaid programs identified limitations on this benefit, compared to
approximately 56% of SCHIP programs (see Table 4).
Under Medicaid, 68% (35 programs) of all programs set a single overall
quantity limit, usually expressed in terms of pair(s) of eye glasses per year(s). Of
these programs, several indicated that they would provide an initial pair of eye
glasses, but subsequent repairs/replacements would require prior authorization. In
eight of the 35 programs with specified quantity limits on eye glasses, additional
corrective lenses were available only based upon beneficiary diagnosis and/or
condition (e.g., one pair per year unless prescription changes 0.75 diopters,34 or axis
changes of 15 degrees). Some programs also indicated that eye glasses could be
replaced if lost or broken. In four programs (Georgia, New Mexico, Oklahoma, and
Tennessee) prior authorization was required to access eye glasses.
Under SCHIP, the specified benefit limits were similar to those under Medicaid.
A majority of the programs set a single overall quantity limit, usually expressed in
terms of pair(s) of eye glasses per year(s). As under Medicaid, several programs
indicated that they would provide an initial pair of corrective lenses, but repairs or
replacement would require prior authorization. One major difference between the
Medicaid and SCHIP coverage limitations was the use of dollar-based limitations
under SCHIP. In five programs (Colorado, Connecticut-A, Iowa, North Dakota, and
West Virginia) the states set a dollar-based maximum limit for eyeglasses during a
given benefit period (see Appendix D).
34 A diopter is a unit of measure used by eye care specialists to measure the refractive power
of a lense whose focal length is one meter.

CRS-20
Table 4. Coverage of, and Limits for Monitoring of, Eye Glasses
for Children under Medicaid and SCHIP (as of June 2000)
Medicaid (51 programs in 50
states and DC)
SCHIP (41 programs
Program classifications
CN only
CN + MN
in 33 states)
Programs that do not cover
1 — DE
0
6 — CA-B, CT-B, CT-C,
eye glasses
FL-B, NY, and UT
Programs with unlimited
6 — AK, CO,
7 — IL, KS, MA,
9 — DE, FL-C, IL, MA-A,
eye glasses coverage
NV, OR, RI,
MN, PA, TX, and
MA-C, NJ-A, NV, OR, and
and SD
WV
WY
Programs with specified
8 — AL, ID,
27 — AR, CA,
23 — AL, AZ, CA-A, CO,
limits and/or monitoring of
IN, MO, MS,
DC, FL, GA, HI,
CT-A, FL-A, GA, IA, KY,
eye glasses
OH, SC, and
IA, KY, LA, MD,
ME, MI, MS, MT, NC, ND,
WY
ME, MI, MT, NC,
NH, NJ-B, PA, TX, VA,
ND, NE, NH, NJ,
VT, WA, and WV
NM, NY, OK, TN,
UT, VA, VT, WA,
and WI
Programs for which limits
1 — AZ
1 — CT
3 — IN, KS, and MA-B
on eye glasses were not
specified
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs
and the other for separate state SCHIP programs, conducted by the National Academy for State Health
Policy under contract to CRS.
Notes: State abbreviations are used in this table. In the Medicaid column, the subcolumn labeled “CN
only” means that coverage, limitations and monitoring of vision services apply only to beneficiaries
classified as categorically needy, and the subcolumn labeled “CN + MN” means that coverage,
limitations and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the “CN + MN”
subcolumns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were Alaska, Alabama, Arizona,
Colorado, Delaware, Idaho, Indiana, Missouri, Mississippi, New Mexico, Nevada, Ohio, South
Carolina, South Dakota, and Wyoming. These 15 states are always listed in the “CN Only”
subcolumn.
In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one such
program with different benefit plans. Two states (California and New Jersey) each had two separate
SCHIP programs. In this case, an A or B extension was added to the state abbreviation to distinguish
these programs (e.g., California-A, California-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension was
added to the state abbreviation to distinguish these multiple programs (e.g., Connecticut-A,
Connecticut-B, Connecticut-C).
The Nature of Benefit Limits for Children under Medicaid and
SCHIP. It is important to note that comparing quantity limits under Medicaid and
SCHIP must be done with care because the term “limits” does not have the same

CRS-21
meaning across these two programs. For example, state Medicaid plans may indicate
that children are limited to one eye exam per year. But children who need more than
one such visit in a year can obtain additional visits, as long as the provider of care
demonstrates the medical necessity for more visits. Stated limits on benefits under
Medicaid reflect what providers can generally expect to be paid for in the absence of
official clearance for more services, rather than absolute limits on what beneficiaries
may receive, although additional conditions governing provider reimbursement (e.g.,
prior authorization) may effectively alter receipt of services. In addition, as noted
above, when medically necessary for children, all benefits (mandatory or optional)
are essentially unlimited due to EPSDT. By contrast, separate SCHIP programs are
modeled after private sector, commercial insurance products. Under commercial
insurance products, benefits are always limited by medical necessity, but other limits
may apply as well. For this reason, under SCHIP quality limits are sometimes more
restrictive.
Conclusion
A small but significant proportion of children have visual impairments. When
detected early, many childhood vision abnormalities are treatable, but the potential
for correction and normal visual development diminishes with age. Medicaid and
SCHIP provide access to an array of vision-related services including screening that
can help children in low- to moderate-income families overcome these difficulties.
Medicaid’s mandatory EPSDT benefit ensures access to vision screening
services for children. Under EPSDT, state-specific periodicity schedules for vision
screening services are often in accordance with the AAP recommendations.
However, CMS does not require states to summit such schedules as a part of their
state plans for approval. In addition, in FY1998, the last year in which data on vision
screening services under EPSDT were collected, just over 14% of EPSDT-eligible
children received a vision screen. This measure is somewhat misleading, however,
because there are several other Medicaid benefit categories (e.g., well-child care, and
physician services) where vision screening services may be delivered. Often such
services are billed as a part of a well-child visit.
Under SCHIP, state-specific benefit packages must provide well-baby and well-
child care, which includes a vision screening component. Like Medicaid, CMS does
not require states to submit their well-baby and well-child or vision screening
periodicity schedules as a part of their SCHIP state plan, nor (except in the case of
immunizations) has CMS endorsed a specific professional standard (i.e., periodicity
schedules) for well-baby and well-child care coverage under SCHIP plans. As with
Medicaid, the well-child coverage requirement is not the only service category where
children could receive vision screening under SCHIP. Children may also receive
vision screening services under other SCHIP covered services such as physician
services and other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic, or rehabilitative services.
A June 2000 CRS benefits survey gives us some clues about access to vision
screening services under SCHIP Medicaid expansion programs and separate state

CRS-22
programs. At that time, nearly all Medicaid and SCHIP programs covered vision
services (e.g., vision screenings, eye exams, treatment of eye diseases or visual
impairments such as eye surgery or eye glasses) for children, and most also covered
eye glasses, either as a part of their eye glass coverage or as a part of their vision
services. Except in a few states where vision-benefit limits under SCHIP were
defined in terms of the AAP or state-specific periodicity schedule, these survey data
do not answer the question “how many screenings are covered and at what ages do
the screenings occur?” However, the survey data do indicate that the breadth of
vision-related benefits available under these two programs likely differs within and
across states.
Coverage policies and benefit limits for the lowest-income children as described
in state Medicaid plans are seldom absolute because of EPSDT. For nearly all
Medicaid children, states are required to provide all federally-allowed treatment to
correct identified problems, even if the specific treatment needed is not otherwise
covered under a state’s Medicaid plan. As a result, when a Medicaid agency reports
that a specific benefit is not covered for children, that means the service is available
only when delivery of that service meets the EPSDT requirement. In these
circumstances, providers typically go through a prior authorization process to receive
payment for what are sometimes called “EPSDT extended benefits.”
Services for higher-income children under SCHIP are sometimes more
restrictive. Unlike Medicaid, but consistent with federal statute, separate SCHIP
programs are modeled after private sector, commercial insurance products. The
requirement to use benchmark plans (or actuarial equivalents of those plans), most
of which are state employee health plans or commercial HMO plans, provides the
framework for defining benefit limits. Under commercial insurance products,
benefits are always limited by medical necessity, but other limits may apply and will
vary by insurance product, as do procedures to monitor for medical need and
appropriateness. Payments to providers participating in these plans may be altered
based on the outcome of such service utilization reviews, which can in turn affect
access to care.

CRS-23
Appendix A. Specified Limits and/or Monitoring of Well-Child (Non-EPSDT) Services for Children
under Medicaid and SCHIP (as of June 2000)
Medicaid
SCHIP
Provider,
Covered
service, or
Provider, service or
Programs
groups
General quantity limits
condition limits
Programs
General quantity limits
condition limits
AK
CN only
UNLIMITED
AK
N/A
AL
NOT COVERED OUTSIDE OF EPSDT*
AL
Follow AAP guidelines
AR
CN + MN
UNLIMITED
AR
N/A
AZ
CN only
Varies by MCO;
AZ
NOT REPORTED
Varies by MCO
no FFS
CA
CN + MN
CA-A
NOT REPORTED
Varies by MCO
UNLIMITED
CA-B
NOT REPORTED
Varies by MCO
CO
CN only
UNLIMITED
CO
UNLIMITED
CT
CN + MN
CT-A
NOT REPORTED
UNLIMITED
CT-B
NOT COVERED
CT-C
NOT COVERED
DC
CN + MN
UNLIMITED
DC
N/A

CRS-24
Medicaid
SCHIP
Provider,
Covered
service, or
Provider, service or
Programs
groups
General quantity limits
condition limits
Programs
General quantity limits
condition limits
DE
CN only
UNLIMITED
DE
UNLIMITED
FL
FL-A
UNLIMITED
NOT COVERED OUTSIDE OF EPSDT*
FL-B
UNLIMITED
FL-C
UNLIMITED
GA
CN + MN
GA
Some services covered, some
UNLIMITED
limitations.
HI
CN + MN
UNLIMITED
HI
N/A
IA
CN + MN
UNLIMITED
IA
UNLIMITED
ID
CN only
AAP recommended periodicity
ID
N/A
IL
CN + MN
All well-child visits are
IL
UNLIMITED
considered EPSDT
IN
CN only
UNLIMITED
IN
NOT REPORTED
KS
CN + MN
UNLIMITED
KS
UNLIMITED
KY
CN + MN
UNLIMITED
KY
UNLIMITED
LA
NOT COVERED OUTSIDE OF EPSDT*
LA
N/A
MA
MA-A
UNLIMITED
NOT COVERED OUTSIDE OF EPSDT*
MA-B
UNLIMITED
MA-C
UNLIMITED

CRS-25
Medicaid
SCHIP
Provider,
Covered
service, or
Provider, service or
Programs
groups
General quantity limits
condition limits
Programs
General quantity limits
condition limits
MD
CN + MN
UNLIMITED
MD
N/A
ME
CN + MN
UNLIMITED
ME
UNLIMITED
MI
CN + MN
UNLIMITED
MI
UNLIMITED
MN
CN + MN
UNLIMITED
MN
N/A
MO
CN only
UNLIMITED
MO
N/A
MS
NOT COVERED OUTSIDE OF EPSDT*
MS
NOT REPORTED
MT
CN + MN
UNLIMITED
MT
UNLIMITED
NC
NC
three visits per year for children
ages 1-3, one visit per year ages
NOT COVERED OUTSIDE OF EPSDT*
4-7. one visit every three years
ages 7-19
ND
CN + MN
ND
0-12 months-seven visits, 13-24
UNLIMITED
months-three visits, 25 months-18
years-one per benefit period
NE
CN + MN
UNLIMITED
NE
N/A
NH
CN + MN
UNLIMITED
NH
UNLIMITED
NJ
NJ-A
UNLIMITED
UNLIMITED
NJ-B
UNLIMITED
NM
CN only
UNLIMITED
NM
N/A

CRS-26
Medicaid
SCHIP
Provider,
Covered
service, or
Provider, service or
Programs
groups
General quantity limits
condition limits
Programs
General quantity limits
condition limits
NV
CN only
UNLIMITED
NV
UNLIMITED
NY
CN + MN
UNLIMITED
NY
NOT REPORTED
OH
CN only
24 physician visits per year
OH
N/A
OK
NOT COVERED OUTSIDE OF EPSDT*
OK
N/A
OR
CN only
UNLIMITED
OR
UNLIMITED
PA
CN + MN
UNLIMITED
PA
UNLIMITED
RI
CN + MN
UNLIMITED
RI
N/A
SC
CN only
UNLIMITED
SC
N/A
SD
CN only
UNLIMITED
SD
N/A
TN
CN + MN
per EPSDT guidelines
subject to MCO
TN
N/A
approval
TX
NOT COVERED OUTSIDE OF EPSDT*
TX
UNLIMITED
UT
CN + MN
not more than one/day
UT
UNLIMITED
VA
NOT COVERED OUTSIDE OF EPSDT*
VA
UNLIMITED
VT
CN + MN
UNLIMITED
VT
UNLIMITED
WA
NOT COVERED OUTSIDE OF EPSDT*
WA
UNLIMITED
WI
CN + MN
UNLIMITED
WI
N/A
WV
CN + MN
UNLIMITED
WV
Follow AAP schedule

CRS-27
Medicaid
SCHIP
Provider,
Covered
service, or
Provider, service or
Programs
groups
General quantity limits
condition limits
Programs
General quantity limits
condition limits
WY
NOT COVERED OUTSIDE OF EPSDT*
WY
UNLIMITED
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted by the National
Academy for State Health Policy under contract to CRS.
Notes: In the two “Programs” columns (one for Medicaid and one for SCHIP), state abbreviations are used. For SCHIP, 28 states had a single separate SCHIP program represented
by the state abbreviation. The remaining five states with separate SCHIP programs each had two or three such programs with different benefit plans. In this case, an A, B, or C extension
was added to the state abbreviation (e.g., Connecticut-A, Connecticut-B, Connecticut-C) to distinguish multiple programs as needed.
In the “Covered groups” column for Medicaid, “CN only” means this benefit is covered for categorically needy beneficiaries only, and “CN + MN “ means this benefit is covered for
both categorically needy and medically needy beneficiaries.
Under the SCHIP columns, N/A means that the state had no separate SCHIP program at the time of the survey, and thus, coverage of this benefit is not applicable.
* Under Medicaid, all states cover well-child care and screening services under the mandatory EPSDT benefit. These states chose not to cover well-child care and screening services
outside of EPSDT as well.
Definition of other terms (in alphabetical order):
AAP — American Academy of Pediatrics
EPSDT — Early Periodic Screening Diagnosis and Treatment Program
FFS — Fee-for-service
MCO — managed care organization

CRS-28
Appendix B. Specified Limits and/or Monitoring of Physician
Services for Children under Medicaid and SCHIP
(as of June 2000)
Medicaid
SCHIP
Service not included in the
Programs
Medicaid survey (see note)
Programs
General quantity limits
AK
AK
N/A
AL
AL
NOT REPORTED*
AR
AR
N/A
AZ
AZ
NOT REPORTED*
CA
CA-A
NOT REPORTED*
CA-B
NOT REPORTED*
CO
CO
NOT REPORTED*
CT
CT-A
NOT REPORTED*
CT-B
NOT REPORTED*
CT-C
NOT COVERED*
DC
DC
N/A
DE
DE
NOT REPORTED*
FL
FL-A
NOT REPORTED*
FL-B
NOT REPORTED*
FL-C
NOT REPORTED*
GA
GA
NOT REPORTED*
HI
HI
N/A
IA
IA
NOT REPORTED*
ID
ID
N/A
IL
IL
NOT REPORTED*
IN
IN
NOT REPORTED*
KS
KS
NOT REPORTED*
KY
KY
NOT REPORTED*
LA
LA
N/A
MA
MA-A
NOT REPORTED*
MA-B
NOT REPORTED*
MA-C
NOT REPORTED*

CRS-29
Medicaid
SCHIP
Service not included in the
Programs
Medicaid survey (see note)
Programs
General quantity limits
MD
MD
N/A
ME
ME
NOT REPORTED*
MI
MI
NOT REPORTED*
MN
MN
N/A
MO
MO
NOT COVERED
MS
MS
NOT REPORTED*
MT
MT
NOT REPORTED*
NC
NC
NOT REPORTED*
ND
ND
NOT REPORTED*
NE
NE
N/A
NH
NH
NOT REPORTED*
NJ
NJ-A
NOT REPORTED*
NJ-B
NOT REPORTED*, **
NM
NM
N/A
NV
NV
NOT REPORTED*
NY
NY
NOT REPORTED*
OH
OH
N/A
OK
OK
N/A
OR
OR
NOT REPORTED*
PA
PA
NOT REPORTED*
RI
RI
N/A
SC
SC
N/A
SD
SD
N/A
TN
TN
N/A
TX
TX
NOT REPORTED*
UT
UT
NOT REPORTED*
VA
VA
NOT REPORTED*
VT
VT
NOT REPORTED*
WA
WA
NOT REPORTED*
WI
WI
N/A

CRS-30
Medicaid
SCHIP
Service not included in the
Programs
Medicaid survey (see note)
Programs
General quantity limits
WV
WV
NOT REPORTED*
WY
WY
NOT REPORTED*
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs
and the other for separate state SCHIP programs, conducted by the National Academy for State Health
Policy under contract to CRS.
Notes: In the two “Programs” columns (one for Medicaid and one for SCHIP), state abbreviations
are used. For SCHIP, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had two or three such
programs with different benefit plans. In this case, an A, B, or C extension was added to the state
abbreviation (e.g., Connecticut-A, Connecticut-B, Connecticut-C) to distinguish multiple programs
as needed.
The amount, duration, and scope of physician services was not captured on the Medicaid benefits
survey because coverage of physician services is mandatory under Medicaid. When medically
necessary for children, all benefits (mandatory or optional) are essentially unlimited due to EPSDT.
* On the SCHIP benefits survey, states were only asked to report covered/not covered for their
coverage of physician services. States were not required to report quantity limits for physician
services as the types of physicians covered under this benefit are diverse (e.g., dentists,
ophthalmologists, and general practitioners), and the programs generally allow for coverage that
is within the scope of practice within each given discipline.
Under the SCHIP columns, N/A means that the state had no separate SCHIP program at the time of
the survey, and thus, coverage of this benefit is not applicable.
** The survey data indicated that NJ-B’s separate state program did not cover physician services,
however conversations with individuals responsible for administering the CRS-sponsored
benefit survey at the National Academy for State Health Policy agreed that this survey response
was likely a result of reporting error. New Jersey’s separate state program, NJ-B, offers
FEHBP-equivalent coverage, and physician services are included in the FEHBP benefit
package.

CRS-31
Appendix C. Specified Limits and/or Monitoring of Vision Services for Children
under Medicaid and SCHIP (as of June 2000)
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
AK
CN only
UNLIMITED
AK
N/A
AL
CN only
one eye exam
AL
one exam each
every two years
calendar year
— more if
medically
necessary
AR
CN + MN
one exam per 12
AR
N/A
months
AZ
CN only
Varies by MCO;
AZ
Exams for
no FFS
prescription lenses
limited to one visit
per year
CA
CN + MN
CA-A
one exam and pair
Varies by MCO
of eye glasses per
UNLIMITED
year
CA-B
NOT COVERED
CO
CN only
UNLIMITED
CO
UNLIMITED
CT
CN + MN
CT-A
NOT REPORTED
UNLIMITED
CT-B
NOT COVERED
CT-C
NOT COVERED

CRS-32
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
DC
CN + MN
UNLIMITED
DC
N/A
DE
CN only
one per year
Covered in MC
DE
UNLIMITED
only
FL
CN + MN
FL-A
UNLIMITED
UNLIMITED
FL-B
UNLIMITED
FL-C
UNLIMITED
GA
CN + MN
one per year
GA
one visit per year
HI
CN + MN
one refraction per
HI
year — screens
per EPSDT
N/A
periodicity
schedule
IA
CN + MN
one pair per two
IA
refractions limited
Varies by MCO
years
to one per year
ID
CN only
one vision check
ID
N/A
per year
IL
CN + MN
UNLIMITED
IL
UNLIMITED
IN
CN only
one exam per
IN
NOT REPORTED
year
KS
CN + MN
UNLIMITED
KS
UNLIMITED

CRS-33
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
KY
CN + MN
two exams plus
KY
follow up without
UNLIMITED
PA
LA
CN + MN
UNLIMITED
LA
N/A
MA
CN + MN
MA-A
UNLIMITED
NOT REPORTED
MA-B
varies by MCO
MA-C
UNLIMITED
MD
CN + MN
one per year
MD
N/A
ME
CN + MN
PA required for
ME
PA required for
some services
some services like
x
x
like low vision
low vision aids
aids
MI
CN + MN
UNLIMITED
MI
not covered
MN
CN + MN
x
MN
N/A
MO
CN only
one eye exam per
MO
N/A
year
MS
CN only
one eye exam per
MS
NOT REPORTED
year
MT
CN + MN
one eye exam per
MT
UNLIMITED
year
NC
CN + MN
one refraction per
NC
one exam per 12
year without PA
months

CRS-34
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
ND
CN + MN
< age 21, one
ND
one exam every 12
exam per year
months
NE
CN + MN
one exam per
NE
year; more if
need to determine
N/A
presence
suspected
condition
NH
CN + MN
one refraction per
NH
one routine exam
state fiscal year
every 24 months
NJ
CN + MN
NJ-A
one eye exam per
year
x
NJ-B
one eye exam per
year
NM
CN only
exams per
NM
EPSDT
N/A
guidelines
NV
CN only
UNLIMITED
NV
UNLIMITED
NY
CN + MN
one visit per two
NY
not specified
years (refraction)
x
contacts, tinted
lenses, and
orthopic training
require PA

CRS-35
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
OH
CN only
one exam, frame,
OH
and lenses per 12-
N/A
month period
OK
CN + MN
per EPSDT
OK
N/A
guidelines
OR
CN only
UNLIMITED
OR
one per year
PA
CN + MN
Children ages 3-
PA
one exam per year
6 are eligible for
one eye exam per
year. Children
over age 6 are
eligible for eye
exam during their
8th, 10th, 12th, 14th,
16th, 18th, and 20th
year.
Unlimited
eyeglass repair or
replacement of
lost or stolen
glasses
RI
CN only
UNLIMITED
RI
N/A

CRS-36
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
SC
CN only
one exam per
SC
year, one
additional visit if
N/A
one-half diopter
change during
year
SD
CN only
UNLIMITED
SD
N/A
TN
CN + MN
varies by
No FFS
TN
N/A
MCO
TX
CN + MN
TX
one exam per 12
months for
corrective lenses.
UNLIMITED
One pair non-
prosthetic eye
wear per 12
months.
UT
CN + MN
UT
$30 maximum
UNLIMITED
limit
VA
CN + MN
one visit per year
VA
one exam every
without PA
two years
VT
CN + MN
VT
one
comprehensive
UNLIMITED
and interim exam
every 12 months

CRS-37
Medicaid
SCHIP
Requires PA
Provider,
or other
General
service, or
Requires PA or
General quantity
Provider, service
Programs
Covered groups
review
quantity limits
condition limits
Programs
other review
limits
or condition limits
WA
CN + MN
WA
x
one exam per year,
UNLIMITED
more frequently if
problem
WI
CN + MN
x — all
WI
contacts,
special lenses
N/A
frames must
have PA
WV
CN + MN
UNLIMITED
WV
annual exam
WY
CN only
UNLIMITED
WY
UNLIMITED
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted by the National
Academy for State Health Policy under contract to CRS.
Notes: In the two “Programs” columns (one for Medicaid and one for SCHIP), state abbreviations are used. For SCHIP, 28 states had a single separate SCHIP program represented
by the state abbreviation. The remaining five states with separate SCHIP programs each had two or three such programs with different benefit plans. In this case, an A, B, or C
extension was added to the state abbreviation (e.g., CT-A, CT-B, CT-C) to distinguish multiple programs as needed. In the “Covered groups” column for Medicaid, “CN only” means
this benefit is covered for categorically needy beneficiaries only, and “CN + MN “ means this benefit is covered for both categorically needy and medically needy beneficiaries.
Under the SCHIP columns, N/A means that the state had no separate SCHIP program at the time of the survey, and thus, coverage of this benefit is not applicable.
Definition of other terms (in alphabetical order):
EPSDT — Early Periodic Screening Diagnosis and Treatment Program
FFS — Fee-for-service
MC — managed care
MCO — managed care organization
PA — prior authorization

CRS-38
Appendix D. Specified Limits and/or Monitoring of Eye Glasses for Children
under Medicaid and SCHIP (as of June 2000)
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
AK
CN only
UNLIMITED
AK
N/A
AL
CN only
one every two
AL
years — more if
one pair per year
medically
necessary
AR
CN + MN
one pair per 12
AR
N/A
months
AZ
CN only
Varies by
AZ
one pair per
MCO; no FFS
contract year
CA
CN + MN
one pair per year
CA-A
one pair per year
Varies by MCO
without PA
CA-B
NOT COVERED
CO
CN only
CO
$50 credit
towards purchase
UNLIMITED
per benefit
period

CRS-39
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
CT
CN + MN
some limits on re-
CT-A
Allowance of
Varies by MCO
placements
$100 every two
consecutive
continuous
eligibility
periods. In some
certain
situations,
optical hardware
is not limited
benefit, and the
allowance
limitations do
not apply.
CT-B
NOT COVERED
CT-C
NOT COVERED
DC
CN + MN
all contact lenses
DC
and special glasses
require PA; will
N/A
replace and repair
glasses
DE
not covered
DE
UNLIMITED
FL
CN + MN
two pair per year
FL-A
one pair/two yrs.
Unless size/RX
changes
FL-B
NOT COVERED

CRS-40
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
FL-C
UNLIMITED
GA
CN + MN
x
PA required for
GA
x
PA required for
contact lenses;
contact lenses,
new glasses unless
trifocal lenses,
prescription
oversized
change meets
frames, hi-index
Medicaid
and poly-
requirements
carbonate lenses.
HI
CN + MN
one pair every two
HI
N/A
years w/out PA
IA
CN + MN
one pair per two
IA
Max $100 to
Varies by MCO
years
include one pair
of frames every
two years and
one set of
prescribed
corrective lenses
per calendar year
ID
CN only
one every four
ID
N/A
years
IL
CN + MN
UNLIMITED
IL
UNLIMITED

CRS-41
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
IN
CN only
one pair per year
IN
unless prescription
changes .75
diopters or axis
NOT REPORTED
changes 15
degrees; replaced
if lost or broken
KS
CN + MN
KS
NOT
varies by MCO
UNLIMITED
REPORTED
KY
CN + MN
two pair per year
KY
x
two pair of
w/out PA
glasses per 12
months
LA
CN + MN
one pair per year;
LA
all repairs/
N/A
replacements
require PA
MA
CN + MN
MA-A
UNLIMITED
UNLIMITED
MA-B
varies by MCO
MA-C
UNLIMITED
MD
CN + MN
one pair per year
MD
unless prescription
N/A
changes, or lost,
stolen, or broken

CRS-42
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
ME
CN + MN
two pair per year
ME
x
PA required for
w/out prior
over two pair per
authorization
year
MI
CN + MN
under age 21, two
MI
Once per 24
replacements per
months, or once
year
per 12 months if
change in
prescription is
needed.
MN
CN + MN
UNLIMITED
MN
N/A
MO
CN only
one pair every two
MO
N/A
years
MS
CN only
two eyeglasses per
MS
year, four lenses
one pair per year
per year
MT
CN + MN
one pair per year
MT
One pair per
Varies by MCO
child per benefit
year; contacts
not covered
NC
CN + MN
one pair per year
NC
one set lenses per
year, one set of
frames every two
years

CRS-43
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
ND
CN + MN
< age 21, one pair
ND
Frames-once
per year
every two years,
$80 max. benefit
for prescribed
lenses once
every 12 months.
NE
CN + MN
First pair
NE
replacement of
lenses and frames
when no longer
useable,
N/A
replacement of
lenses when
prescription
change is
significant enough
NH
CN + MN
one pair per year if
NH
one pair per year
diopter change is
w/limited frame
more than + or -
selection
0.5.
NJ
CN + MN
one pair per year
NJ-A
UNLIMITED
NJ-B
one pair in a 24
month period or
as medically
necessary

CRS-44
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
NM
CN only
x
one pair and
NM
prescribed
replacement w/out
prior
N/A
authorization, all
contacts require
prior authorization
NV
CN only
UNLIMITED
NV
UNLIMITED
NY
CN + MN
one pair every two
NY
years
NOT COVERED
OH
CN only
one frame, and
OH
lenses per 12
N/A
month period
OK
CN + MN
x
As prescribed to
OK
correct visual
defects or protect
N/A
children with
monocular vision;
some require PA
OR
CN only
UNLIMITED
OR
one pair per year
PA
CN + MN
Unlimited
PA
eyeglass repair or
replacement of
two pair per year
lost or stolen
glasses

CRS-45
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
RI
CN only
UNLIMITED
RI
N/A
SC
CN only
one pair per year +
SC
additional lenses if
N/A
one-half diopter
change
SD
CN only
UNLIMITED
SD
N/A
TN
CN + MN
x
covered upon
TN
justified need for
N/A
replacement
TX
CN + MN
TX
one pair non-
prosthetic eye
UNLIMITED
wear per 12
months.
UT
CN + MN
one pair per two
UT
NOT COVERED
years
VA
CN + MN
one pair per two
VA
one pair per two
years
years
VT
CN + MN
no replacement
VT
One pair every
within 24 months
two years unless
if not broken or
one-half diopter
lost and change is
change
less than one-half
diopter

CRS-46
Medicaid
SCHIP
Provider,
Requires PA
service, or
Requires PA
Covered
or other
General quantity
condition
or other
General
Provider, service or
Programs
groups
review
limits
limits
Programs
review
quantity limits
condition limits
WA
CN + MN
one per two years
WA
one pair every
two years
WI
CN + MN
two pair per year
WI
N/A
WV
CN + MN
WV
Contacts and
eyeglasses
UNLIMITED
limited to $100
per 12 months
WY
CN only
initial pair and
WY
periodic
UNLIMITED
replacement
Source: CRS analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted by the National
Academy for State Health Policy under contract to CRS.
Notes: In the two “Programs” columns (one for Medicaid and one for SCHIP), state abbreviations are used. For SCHIP, 28 states had a single separate SCHIP program represented
by the state abbreviation. The remaining five states with separate SCHIP programs each had two or three such programs with different benefit plans. In this case, an A, B, or C extension
was added to the state abbreviation (e.g., CT-A, CT-B, CT-C) to distinguish multiple programs as needed.
In the “Covered groups” column for Medicaid, “CN only” means this benefit is covered for categorically needy beneficiaries only, and “CN + MN “ means this benefit is covered for
both categorically needy and medically needy beneficiaries.
Under the SCHIP columns, N/A means that the state had no separate SCHIP program at the time of the survey, and thus, coverage of this benefit is not applicable.
Definition of other terms (in alphabetical order):
FFS — fee for service
MCO — managed care organization
PA — prior authorization

EveryCRSReport.com
The Congressional Research Service (CRS) is a federal legislative branch agency, housed inside the
Library of Congress, charged with providing the United States Congress non-partisan advice on
issues that may come before Congress.
EveryCRSReport.com republishes CRS reports that are available to al Congressional staff. The
reports are not classified, and Members of Congress routinely make individual reports available to
the public.
Prior to our republication, we redacted names, phone numbers and email addresses of analysts
who produced the reports. We also added this page to the report. We have not intentional y made
any other changes to any report published on EveryCRSReport.com.
CRS reports, as a work of the United States government, are not subject to copyright protection in
the United States. Any CRS report may be reproduced and distributed in its entirety without
permission from CRS. However, as a CRS report may include copyrighted images or material from a
third party, you may need to obtain permission of the copyright holder if you wish to copy or
otherwise use copyrighted material.
Information in a CRS report should not be relied upon for purposes other than public
understanding of information that has been provided by CRS to members of Congress in
connection with CRS' institutional role.
EveryCRSReport.com is not a government website and is not affiliated with CRS. We do not claim
copyright on any CRS report we have republished.