The landscape of Medicaid billing for optometry services in Florida is about to change. In 2025, the state is rolling out updated Medicaid Managed Care (MMC) policies that will significantly impact how optometrists document, code, and submit claims. While these changes aim to improve access and streamline care coordination, they also introduce new billing complexities that providers can’t afford to overlook.

What’s Changing in Florida Medicaid Managed Care in 2025?

Florida’s Agency for Health Care Administration (AHCA) is transitioning to a new five-year managed care contract cycle beginning in July 2025. The update includes:

• New Medicaid Managed Care Organizations (MCOs): AHCA has selected a revised list of insurers who will manage Medicaid benefits across the state. This means changes in provider enrollment, payer portals, and prior authorization requirements.
• Expanded vision coverage for specific populations: Children and adults with chronic conditions will see more frequent eligibility for comprehensive eye exams and certain diagnostic procedures.
• Tighter utilization controls and documentation audits: Plans will be given more authority to deny claims that lack clinical necessity or complete documentation—especially for high-frequency procedures like fundus photography and OCT

These changes will affect all Medicaid MCOs operating in Florida, including Sunshine Health, Humana Healthy Horizons, Simply Healthcare, and others.

Key Billing Concerns for Optometrists

1. New Payer Portals & Authorization Workflows:

Optometrists may need to re-enroll with new MCOs and adapt to new authorization systems. This can delay approvals and impact reimbursement if not managed proactively.

2. Increased Scrutiny of CPT Codes:

Billing for procedures like 92250 (fundus photography) or 92133/92134 (OCT) will now require more robust documentation of medical necessity—especially in repeat cases. Your claims must clearly justify why services go beyond routine vision care.

3. Modifiers Matter More:

Insurers expect documentation to reflect not just what was done in the session, but why—and whether the patient is improving. Notes should show measurable goals and how current treatment strategies aim to meet them.

4. Routine vs. Medical Exams:

Plans will be more aggressive in denying "routine" exams that are coded as medical. You’ll need to ensure that your E/M code or 92xxx series code aligns with documentation that supports the medical nature of the visit.

How to Prepare Your Practice

• Audit your documentation protocols: Make sure SOAP notes clearly support the services billed. Clinical findings, patient history, and follow-up plans must be detailed and consistent.
• Verify patient eligibility and plan coverage in real time: With multiple MCOs in play, knowing what’s covered—and under which plan—is critical.
• Work with a billing partner who understands Florida’s Medicaid system: Expert chiropractic and optometry billing services—like those offered by Instapay Healthcare Services—can help reduce denials and improve cash flow.

Final Thoughts

Florida’s 2025 Medicaid Managed Care overhaul brings both challenges and opportunities. Optometrists who stay informed and proactively adapt their billing workflows will be best positioned to navigate the changes. Whether you’re a solo provider or a multi-location practice, ensuring accuracy in Medicaid billing isn’t optional—it’s essential.

Instapay Healthcare Services specializes in helping Florida providers simplify billing and stay compliant. Let Instapay Healthcare Services help you navigate the 2025 changes for optometry billing with confidence.