Does Medicaid Cover Cataract Surgery?

Does Medicaid Cover Cataract Surgery – Overview

Many Americans access health services through Medicaid. Programs under Medicaid must adhere to federal laws, and 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 mandatory for children and young adults under 21 years 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.

Private insurance firms may offer supplemental vision benefits, but financial assistance for cataract surgery specifically because one qualifies for Medicaid is not guaranteed.

Medicaid and Cataract Surgery

Cataract surgery is widespread among adults 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 covers vision screening as part of each Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service visit.

If a vision screening during an EPSDT service reveals issues that warrant further examination and treatment, Medicaid covers the costs of those necessary procedures.

For adults, routine eye exams are generally not covered by Medicaid unless deemed medically necessary.

However, if a physician detects an eye condition and deems it a primary concern, 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 the following:

1. The frequency of routine vision examinations for children and young adults under Medicaid varies by state.

2. An allowance towards eyewear (one frame and two lenses).

3. Coverage of frames and lenses for children and young adults under Medicaid varies by state. 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 to the Medicaid office showing the necessity of the service.

5. Any other eyewear or vision services are deemed medically necessary. In this case, written documents showing service necessity 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 $1,500 per eye, while specialty lenses can cost a nerve-wracking $3,000 per 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 outside your plan, and you might have to pay for them out-of-pocket.

If you qualify for Medicare, you must pay 20% of the Medicare-approved expenses for your cataract surgery, including any needed corrective lenses after surgery, plus the Medicare Part B deductible.

Upgraded or expensive eyewear and contact lenses are not covered; you must 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 healthcare insurance firms such as United Healthcare, Aetna, and Blue Shield offer supplemental vision benefits when subscribing.

So, if you can afford to get third-party health care insurance coverage, 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 cataract surgeon or ophthalmologist charges the fee.

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 determining your out-of-pocket expenses is your Medicaid plan.

Final Thought on Medicaid’s Cataract Surgery Coverage

To sum it up, Medicaid could pay for your cataract surgery because it falls under the optional benefits determined state-by-state.

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 the extent of coverage for vision care that your plan provides.

See Also

Does Medicaid Cover Vision

Does Medicaid Cover Braces

Does Medicare Cover Hearing Aids

Current Version
August 10, 2023
Updated By
Andrea Morales G.
April 14, 2024
Updated By
Andrea Morales G.

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