Does Medicaid Cover Cataract Surgery? – Overview
Many Americans access health services through Medicaid. Programs under Medicaid must adhere to federal laws by they are structured on a state-by-state basis.
Coverage for vision care, including cataract surgery, is an optional benefit and individual states determine coverage.
Vision benefits are deemed mandatory for children and young adults under 21 years who are covered by Medicaid.
However, as an adult, vision benefits are not guaranteed. Vision benefits extended to adults include eye exams, eyewear, and medically necessary procedures.
Cataract surgery can be pricey even when you have coverage under Medicaid. This will depend on the out-of-pocket expenses under your Medicaid plan.
Not to worry, private insurance firms provide financial assistance for cataract surgery to persons who qualify for Medicaid.
Medicaid and Cataract Surgery
Cataract surgery is a very common procedure among adults who are 60 years and above to restore vision impacted by cloudy lenses.
Medicaid includes some benefits to help deal with vision impairment, such as eye exams, eyewear, and even cataract surgery.
Persons who qualify for Medicaid benefits include children, persons with disabilities, low-income persons, pregnant women, and adults below 65 years.
Each State determines the vision benefits included in its plan.
For kids, Medicaid pays for eye exams for each health checkup a child goes for.
If the checkup reveals any issues such as cataracts that warrant further examination and treatment, then the costs of those additional procedures will be paid for by Medicaid.
For adults, Medicaid doesn’t pay for eye exams when you visit a hospital for routine health checkups.
However, if any eye condition is detected by a physician and deemed a primary concern, then Medicaid will pay for the treatment.
How Can You Confirm If Medicaid Will Pay for Your Cataract Surgery?
To learn more about your Medicaid plan and, in this case, if it pays for cataract surgery, you need to contact your State Medicaid office because coverage for optional benefits such as vision depends on your state of residence.
The office can assist with:
1. Medicaid eligibility.
2. Services are covered under your plan.
3. Liens and 3rd party insurance liability.
4. Medicaid claims.
5. Misplaced Medicaid card and the replacement process.
6. How you can find Medicaid-approved physicians close by.
7. The status of your Medicaid application.
Which Cataract Surgery Benefits Do You Receive from Medicaid?
For persons who are 21 years and above and enrolled in Medicaid, they can access:
1. An allowance towards eyewear (one frame and two lenses).
2. Contact lenses are intended to treat cataracts or aphakia.
3. Specialist eye examinations with a recommendation from PCP.
Kids and young adults below 21 years and enrolled in Medicaid, can access:
1. Routine vision examinations are usually done twice a year.
2. An allowance towards eyewear (one frame and two lenses).
3. Two frames and four lenses per year. Note that coverage applies for the second pair of eyewear if the glasses are deemed medically necessary, for instance, if the prescription changes. Also, an exception to limits can be made for special reasons.
4. Replacement for eyewear or contact lenses if they are damaged, lost, or the prescription changes.
When the prescription changes, the service provider must submit written documentation showing the necessity of the service to the Medicaid office.
5. Any other eyewear or vision services are deemed medically necessary. In this case, written documents showing the necessity of service must be submitted to the Medicaid office.
How Much Does a Cataract Surgery Cost?
Cataract surgery can be very pricey, and the total costs depend on the lenses used.
For instance, Toric lenses cost around 1500 USD for each eye, while specialty lenses can cost a nerve-wracking 3000 USD for each eye.
Remember, if your plan includes coverage for cataract surgery, Medicaid will pay for the least expensive alternative.
So if you pick pricey lenses, they will be considered to be outside your plan, and you might have to pay for them out-of-pocket.
If you’re an adult who qualifies for Medicare rather than Medicaid, you’re liable to settle 20% of the expenses approved by Medicare concerning the new corrective lenses needed for your cataract surgery as well as Original Medicare deductibles.
Upgraded or expensive eyewear and contact lenses are not covered, and you have to pay out-of-pocket.
Some other adults qualify for both Medicaid and Medicare. In such an instance, Medicare is deployed as the main coverage for cataract surgery, and Medicaid will come in and pay for the expenses not covered by Medicare.
If you have Medicaid coverage and a 3rd party insurance plan, you can use the supplement insurance coverage to cover the gaps in expenses left by your primary insurance plan.
Most US private health care insurance firms such as United Healthcare, Aetna, and Blue Shield offer you supplemental vision benefits when you subscribe.
So if you can afford to get a 3rd party health care insurance cover, it will come in handy and reduce your out-of-pocket expenses because, as we’ve seen, cataract surgery can be really expensive.
Which Factors Affect the Cost of Cataract Surgery?
The key elements that impact the overall price of cataract surgery include:
1. The kind of IOLs (intraocular lenses) inserted in your eyes.
2. The fee is charged by the cataract surgeon or ophthalmologist.
3. Whether the cataract surgery is an outpatient service.
4. Whether you need to stay in the hospital after surgery.
5. Pre and post-surgery physician appointments and medication.
6. Regional pricing inconsistencies.
7. Although these variables will impact the on-paper cost of your cataract operation, the most significant factor that determines your out-of-pocket expenses is your Medicaid plan.
Final Thought on Medicaid’s Cataract Surgery Coverage
To sum it all up, Medicaid could pay for your cataract surgery because it falls under the optional benefits, which are determined on a state-by-state basis.
However, Medicaid can only cover a portion of the costs of an ordinary cataract surgery procedure.
Therefore, you still incur some out-of-pocket costs when undergoing cataract surgery. You can contact your local Medicaid office to learn more about your plan’s extent of coverage for vision care.
I am a dedicated healthcare researcher and an enthusiast specializing in medical grants, medical education and research. Through my articles, I aim to empower healthcare professionals and researchers with valuable insights and resources to navigate these critical aspects effectively.