Does Medicaid Cover Vision? Medicaid Eye Exam Qualification

Does Medicaid Cover Vision – Overview

The answer to whether Medicaid will pay for your vision care depends on the reason for care, your age, and the state you currently reside in.

Why does the State of residence matter? Because Medicaid benefits are determined on a state-by-state basis.

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Medicaid covers comprehensive vision care for individuals under 21 years as part of the EPSDT benefit.

Under the plan, Medicaid will pay for classifying and correcting vision problems.

However, things get a bit tricky for people over 21 because each US State decides whether and how often Medicaid will pay for their vision care, including eye exams, eyewear, contact lenses, and therapy.

Medicaid coverage for vision care beyond medically necessary procedures varies by state and may include routine exams and eyewear.

What is Vision Care

Vision care is a collective word for various procedures for maintaining healthy and functional eyes. Regular vision care’s primary objective is to ensure you have the best eyesight possible.

Under Medicaid, vision care comprises eye exams, eyewear, and eye surgery. Visual benefits are split into two, and they include:

Mandatory Medicaid Vision Benefits

Federal law mandates that Medicaid programs provide pediatric vision services under EPSDT; adult coverage varies by state and is not federally mandated to include eye exams or eye surgeries.

Optional Medicaid Vision Benefits

Optional vision benefits are those that Medicaid approves for coverage, but they aren’t always necessary. Eyewear and optometry fall under this category, meaning that Medicaid coverage will vary from state to state.

What Does Medicaid Pay For

Medicaid pays for many services related to the diagnosis and treatment of vision problems, including:

Optometry Exams

Guidelines in the State you reside in will determine whether Medicaid will pay for your optometry exams. Optometry exams involve a physician diagnosing and correcting refractive issues: the inability to see an item placed at a certain distance.

Each State decides whether or not to pay for optometry or refractive eye exams and the regularity of optometry exam appointments.

Ophthalmology Exams

Medicaid will pay for ophthalmology exams across all US States under the health insurance section for clinically essential conditions irrespective of the vision benefits covered by the State you reside in.

The physician will diagnose and treat eye disorders with a medical cause in ophthalmology exams. Some of the ophthalmology exams paid for by Medicaid include:

Diabetic retinopathy.
Macular degeneration.
Dry eye syndrome.
Retinal detachment.

Eye Wear

In some instances, Medicaid will pay for prescription eyewear to correct refractive issues. Each State decides whether or not to pay for eyewear.

State guidelines determine how often Medicaid will pay for prescription eyewear to treat your refractive problems. The answer could be once a year, every two to five years, once a lifetime, or even never.

Contact Lenses

Medicaid coverage for contact lenses varies by state but is generally provided when medically necessary. Although contact lenses are more expensive than eyewear, people often prefer them for cosmetic purposes.

It’s for this reason that Medicaid rarely includes them as a benefit. However, there are instances in which Medicaid pays for contact lenses, and they include:

When contact lenses are required because the patient cannot wear spectacles. For instance, when a patient has a missing ear or a defective nose.
When contact lenses are intended to be prosthetic devices, they are deemed medically necessary by a physician.

Vision Therapy

Medicaid coverage for vision therapy varies by state and is typically provided for conditions like amblyopia and strabismus; dyslexia is not treated with vision therapy.

Therefore, the health insurance component may cover visual therapy, although meager payment rates make it hard to find a visual therapist who accepts Medicaid coverage.

Before starting your therapeutic sessions, you need precertification, so have your Medicaid provider write a letter of medical necessity.

Eye Surgery

Medicaid can pay for eye surgeries under the health insurance component, which means that uniform stipulations exist across all US States for medically essential eye surgeries.

Eye surgeries repair injuries to the pupil, iris, cornea, retina, optic nerve, conjunctiva, sclera, and eyelids to prevent disorders such as keratoconus, blepharoplasty, vitrectomy, and pterygium removal.

Cataract Removal

Medicaid covers cataract surgery when deemed medically necessary by a healthcare provider.

In addition, your Medicaid provider may consider the operation medically necessary if the cataract causes vision loss past a certain eyesight measurement.

The physician will replace the faulty natural lens with a synthetic substitute. However, Medicaid’s least expensive alternative rule excludes most premium synthetic lens substitutes.

How Does Medicare Works for Eye Care

Medicare covers eye exams for diabetics and glaucoma patients only; routine eye exams are not covered. Therefore, those fully covered by Medicare should still be prepared to pay for exams.

One way to help avoid the cost is to select a provider with an on-site lab so you can get your glasses while you’re there (saving you time and money).

A better option may be to apply for supplemental insurance through your local state Medicaid program. Most states offer some coverage for eye exams, but the coverage varies widely by state and, in some cases, by county.

In any case, it is typically significantly less expensive than paying out of pocket.

Furthermore, even if your state doesn’t have an optometry program specifically designed to help with eye care costs, they may still be able to direct you toward other programs.

That said, it is important to know who is eligible for Medicaid regarding eye exams, so here you go.

Who Qualifies for Medicaid Eye Exams

Medicaid is an entitlement program that covers low-income individuals and families who meet state-specific eligibility requirements such as:

You may qualify for a Medicaid eye exam if you meet the following requirements:

You are age 19 or over.
Your gross income is less than $1,821 per month.
You have not had an eye exam in the last three years, or if your most recent eye exam was over a year ago.
You do not have a medical condition that prevents you from having an eye exam, such as diabetes, glaucoma, or cataracts.
You do not have insurance that provides prescription eyewear, or it does not cover eyeglasses and contact lenses, or you do not have insurance. Still, your income is too high to qualify for Medicaid (this amount varies by state).
You are a U.S. citizen or legal immigrant and live in the United States.

Income Requirements

Applicants must meet specific income requirements before receiving coverage for their eye exams.

For example, applicants must meet specific income limits in some states based on the number of people living in their households.

For example, in Florida, an applicant must earn less than $907 per month ($10,836 per year) before getting coverage for their eye exams.

On the other hand, if you live in a state that allows you to qualify for Medicaid based on income alone and are under 21 years old, you must have at least one vision exam every year.

If you are above the age of 21 or older, you must have a vision exam every 24 months.

However, if your state requires vision exams based on income, your eligibility will depend on how much monthly money you make.

If you are blind or visually impaired, your Medicaid program will provide eye exam services regardless of income.

Does Medicaid Cover Eye Exams

Medicaid does not cover eye exams unless you are a child. You must have your eyes examined every one to two years.

If you wear glasses, have them reviewed annually for the first three years after you get them and then once every two years. Your eyes should be examined every year if you wear contact lenses.

How Can You Take Advantage of Medicaid’s Vision Benefits

If you have Medicaid visual benefits, you will likely need a referral from a primary care Medicaid provider to see a physician.

Ophthalmology appointments are paid for by the standard health component in your Medicaid coverage through care from a specialty physician. In addition, by getting an approved ophthalmologist, you can take advantage of Medicaid’s visual benefits, such as eye exams.

To contact your local Medicaid outlet, check the webpage Benefits.gov. In this portal, you can filter outlets by State and subcategory (Medicaid) to find the contact information of a Medicaid outlet near you.

You can also request assistance from your eye physician on how to use your Medicaid visual benefits. Unfortunately, some physicians don’t accept Medicaid coverage, but they can refer you to other outlets that accept Medicaid coverage.

Bottom Line

Federal law stipulates that Medicaid pays for visual care if you’re under 21. But if you’re over 21, you must get precertification from a physician approved by Medicaid. So, always confirm the extent of your coverage with your local Medicaid provider.

Medicaid covers eye exams for low-income individuals. However, you must meet particular requirements to be eligible. Medicaid will also cover you if you cannot afford glasses or contact lenses.

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