Does Medicaid Cover Contacts? - Grants for Medical

Does Medicaid Cover Contacts? – Overview

Medicaid is a low-cost health insurance program that helps low-income persons and families.

Medicaid must offer vision benefits to enrollees under 21 through the EPSDT benefit. Still, it does not specifically limit vision coverage to those 21 and under, as states can extend vision benefits to adults.

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.

Medicaid covers well-child appointments at no charge. Medicaid coverage, including for vision services under EPSDT, is distinct from CHIP, although both programs can offer vision benefits to eligible children.

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.

While states have flexibility, the frequency of checkups and replacement of prescription contact lenses and eyeglasses must align with medical necessity and EPSDT requirements for individuals under 21.

States can provide vision benefits to adults on Medicaid, and while federal law does not require states to offer adult vision coverage, it permits them to do so.

In some states, Medicaid vision benefits for 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.

Kids 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 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.

The back of the member services card has a number you can call to learn more about local providers and their services.

What is Medicaid’s Stance on Contact Lenses

Where contact lenses are concerned, it’s important to know the following:

1. Medicaid approval for contact lenses typically requires a determination of medical necessity.

2. This statement is accurate and does not require correction.

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 soft, rigid contact lenses, Medicaid will pay for the least expensive alternative.

What Will Medicaid Cover about Contact Lenses

Medicaid coverage for prescription contact lenses for adults varies by state, with some states offering coverage if deemed medically necessary. 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 no other means exist to correct and restore the person’s vision.

2. Contact lenses are deemed necessary because the recipient cannot wear spectacles, such as a recipient with a defective nose or missing ears.

3. Contact lenses are considered 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 of a more severe eye problem?

Will Medicaid provide coverage? Yes, Medicaid will also cover severe eye conditions because you need to see an eye specialist or an ophthalmologist.

Ophthalmologists perform eye checkups and diagnose and treat eye problems.

They also prescribe meds, spectacles, and contact lenses. As part of their overall health coverage, Medicaid beneficiaries may use their Medicaid benefits for ophthalmologist visits, not limited to vision benefits.

Also, to see an ophthalmologist under your Medicaid plan, you must 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

Beneficiaries can find eye specialists who accept Medicaid by contacting their state Medicaid office or their Medicaid managed care plan for a provider directory. The directory will contain the State Medicaid program, and you can search it 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.

Final Thought

In summary, Medicaid isn’t all-inclusive regarding vision benefits such as contact lenses, but it does help you protect your eyes.

Suppose you intend to use your Medicaid cover to get contact lenses and the following prescription meds. In that case, you must maintain an open line of communication with your local Medicaid office regarding what they will and will not cover.

This will ensure Medicaid can care for your needs as you attempt to correct your vision.