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Vision health is vital for cognitive, neurologic, emotional and physical development in a child with 80% of learning dependent upon a child’s eyesight. However, in southeastern Pennsylvania up to 66% of children do not receive proper vision care. The objective of this study was to identify Medicaid eyeglass replacement benefits, interpretations thereof and to recommend policy changes to improve access to glasses. Study aims included: (1) comparing the four major local Medicaid plans’ benefits and subcontractor policies with Pennsylvania’s Medicaid law; (2) surveying and analyzing the knowledge of the legal provisions and the respective plans’ benefits identified in their member handbooks, by a sample of the plans’ and vision subcontractors’ service staff, 50 eye care practices (practices) and 15 Medicaid parents. Providers and parents were also asked about barriers, e.g. prior authorizations, wait time, out-of-pocket fees, policies and practices of the vision subcontractors, and recommendations for improvement; and (3) drafting policy recommendations to the Department of Human Services to support increased knowledge and implementation of the Medicaid provisions. A mixed-methods approach was used to assess the Medicaid plan provisions and survey findings. Most practices identified coverage for one replacement per year, with out-of-pocket fees for breakage warranties and upgrades, mandatory prior authorization by vision subcontractors, and variations in procedure wait times for decisions. Most Medicaid parents were unaware that replacement eyeglasses were covered or were misinformed by providers/vision sub-contractors. When denied replacement eyeglasses, out-of-pocket fees up to the entire cost of the glasses were required. The study identified systematic barriers to implementing Medicaid vision benefits in Pennsylvania. Policy recommendations, including participants’ recommendations for improving understanding and compliance with the eyeglass replacement provisions, will be submitted to the Department of Human Services. Future studies can assess the outcomes and effectiveness of the proposed Medicaid policy changes.

Presentation: 26 minutes