Does Medicaid Cover Contacts? – Overview
Medicaid is a low-cost health insurance program meant to help low-income persons and families.
Federal laws stipulate that Medicaid provides coverage for vision to beneficiaries who are 21 years and below.
Preventative care, such as eye checkups for kids, could mean that Medicaid won’t need to pay for neglected eye problems in the future.
Eye screenings are part and parcel of checkups for kids, with extra screenings and diagnostics done if an issue is detected.
There is no charge for well-child appointments under Medicaid. Coverage is provided via the CHIP (Children’s Health Insurance Program).
The EPSDT (Early, Periodic, Screening, Diagnostic and Treatment) program under Medicaid offers vision benefits such as contact lenses and eye frames to kids and adolescents aged 21 years and below.
Each state will determine how often these checkups and replacement of prescription contact lenses and eye frames are provided.
Some states will provide vision benefits such as contact lenses to adult Medicaid recipients. However, no federal laws necessitate this.
In some states, vision benefits provided by Medicaid to adults can include contact lenses, eye frames, necessary cataract surgery, screening for glaucoma, and potentially subsidized co-payments.
Who Qualifies for Contact Lenses Under Medicaid?
More than 70 million Americans access healthcare services under Medicaid, which provides healthcare insurance to eligible citizens.
Who is Qualified for Medicaid Contact Lens Coverage?
Depending on the state, persons who qualify for Medicaid vision benefits and, to be precise, contact lenses include:
1. Low-income individuals and families.
2. Pregnant women.
3. Children and adolescents (21 years and below).
4. Persons receiving SSI (Supplemental Security Income).
Exceptions and Other Basic Requirements for Medicaid Contact Lense Coverage
Each state has its own Medicaid program, and vision benefits can be stretched past these basic parameters to cover more people.
Vision screenings can help isolate a potential issue, after which you can be referred for additional diagnostics and eyewear if need be.
Kids who are enrolled under Medicaid can automatically get vision benefits because of federal stipulations, and each state determines the extent of vision coverage for adults.
A physician can assist you in identifying if you qualify for vision benefits and to what extent.
For kids specifically, Medicaid provides complete coverage; there are no out-of-pocket costs such as co-payments.
On the other hand, adults need to pay a small amount as a co-payment to access vision benefits if their state of residence covers them.
If you qualify for Medicaid or if your child qualifies for CHIP, you can apply for vision benefits such as contact lenses through your local Medicaid office.
From there, you will be sent to an approved healthcare provider.
The provider will give you a Medicaid service card that you will use to access healthcare services.
There is a number on the back of the member services card, which you can call to find out more about local providers and the services they offer.
What is Medicaid’s Stance on Contact Lenses?
Where contact lenses are concerned, it’s important to know the following:
1. All contact lenses must be approved beforehand by Medicaid.
2. Medicaid doesn’t pay for contact lenses meant for cosmetic purposes.
3. Medicaid covers both soft and rigid contact lenses (Rigid contacts are covered if the recipient can’t wear the usual soft contacts).
4. If the recipient can wear both soft and rigid contact lenses, Medicaid will pay for the least expensive alternative.
What Will Medicaid Cover about Contact Lenses?
Medicaid usually doesn’t cover prescription contacts for adults. This is because contact lenses are a more expensive treatment option for refractive errors than spectacles, and people often want them for cosmetic reasons. However, there are exceptions to this rule:
1. Contact lenses are deemed medically necessary, and there are no other means to correct and restore the person’s vision.
2. Contact lenses are deemed necessary because the recipient cannot wear spectacles. For instance, a recipient with a defective nose or missing ears.
3. Contact lenses are deemed to be prosthetic devices and fall under health insurance.
4. Contact lenses are meant to correct the following eye conditions. Note that all these conditions can’t be corrected using spectacles. They include:
Astigmatism – A condition whereby a person has blurred and imperfect vision
Aphakia – This condition occurs after a person has undergone cataract surgery.
Anisometropia – A condition whereby both eyes have unequal refractive power
High Ametropia – A condition whereby both eyes have faulty refractive power
Keratoconus – A condition whereby the cornea bulges outward
Keratoconjunctivitis Sicca – A condition whereby a person has dry eyes
Does Medicaid Cover Serious Eye Problems Too?
What if you’re concerned about losing your eyesight or experiencing symptoms that point to a more severe eye problem?
Will Medicaid provide coverage? Yes, Medicaid will cover severe eye conditions as well because you need to see an eye specialist, an ophthalmologist.
Ophthalmologists perform eye checkups and diagnose and treat eye problems.
They also prescribe meds, spectacles, and contact lenses. Unfortunately, you can’t use your Medicaid vision benefit to see an ophthalmologist; instead, you use your physical health Medicaid benefit.
Also, to see an ophthalmologist under your Medicaid plan, you will need to have a referral from your primary care physician.
The same applies when visiting all other specialists, such as dermatologists, cardiologists, etc.
How Can You Find Eye Specialists Who Accept Medicaid?
To find any eye specialist who accepts Medicaid coverage, visit the official Medicaid webpage, where you will find your State Medicaid program, and you can search the directory to find eye specialists in your locale who accept Medicaid.
Your Medicaid card may also have information about the agency managing your plan and how to access the directory of participating healthcare providers.
To sum it all up, Medicaid isn’t all-inclusive when it comes to vision benefits such as contact lenses, but it does help you protect your eyes.
If you intend on using your Medicaid cover to get contact lenses and the prescription meds that follow, you must maintain an open line of communication with your local Medicaid office as to what they will and will not cover.
This will ensure Medicaid can take care of your needs as you attempt to correct your vision.
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.