V5242 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for V5242, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 5 of the 9 states list more than one rate for V5242, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. None of the 9 schedules prints a separate unit for V5242, so each amount is a flat payment for one service as the code defines it.
• Per hour. V5242 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. No Medicare physician fee schedule amount is on file for V5242, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for V5242 run from $32.53 in Wisconsin to $530.22 in Montana, a 16.3x gap in the same unit. Half the states pay more than the median of $396.64 and half pay less. The usual reasons for a spread like this in vision & hearing rates:

• Some states buy eyeglasses through a single contracted laboratory, which changes what a provider is paid for the materials.
• Hearing aids and some lenses are priced at invoice or acquisition cost in some states and at a fixed fee in others.
• Adult vision and hearing benefits are optional for states, so coverage, limits and fees vary widely.

Timing matters too. 1 state set the current rate for V5242 in 2026 or later, while 5 states still pay a rate that took effect in 2022 or earlier. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

What a plan pays for V5242 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 9 states.

In 2 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 6 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 1 state is not classified yet.

• Plans negotiate; the published rate applies out of network (6 states). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
• Plans must pay at least the published rate (2 states). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example Montana managed care.

V5242 is a HCPCS Level II vision, hearing and speech code in the vision & hearing line, billed mostly by optometrists, opticians, audiologists and hearing aid dispensers. V codes cover lenses, frames, prosthetic eyes, hearing aids and related services, generally paid per item and per side.

Vision and hearing materials are billed per item, per lens or per device, and hearing aids per ear (monaural or binaural).

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.