Does Medicaid Cover Vision? – Overview
The answer as to whether Medicaid will pay for your vision care depends on the reason for care, your age, and the US State you currently reside in.
Why does the State of residence matter? Because Medicaid benefits are determined on a state-by-state basis.
Medicaid will pay for vision care for persons under 21 years all over the country if they fall under the EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) plan.
Under the plan, Medicaid will pay for the costs of classifying and correcting vision problems.
However, things get a bit tricky for persons over 21 years old because each US State decides whether and how often Medicaid will pay for their vision care, including eye exams, eyewear, contact lenses, and therapy.
So, Medicaid will only pay for medically necessary eye procedures.
What is Vision Care?
Vision care is a collective word for various procedures involved in 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 laws mandate that each US State Medicaid plan provide coverage for certain visual benefits. For instance, Eye exams and eye surgery fall under this category, meaning that Medicaid will fully pay for them under certain conditions.
Optional Medicaid Vision Benefits
Optional vision benefits are those that Medicaid approves for coverage, but they aren’t always necessary. For instance, 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:
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.
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.
In ophthalmology exams, the physician will diagnose and treat eye disorders with a medical cause. Some of the ophthalmology exams paid for by Medicaid include:
- Diabetic retinopathy.
- Macular degeneration.
- Dry eye syndrome.
- Retinal detachment.
Medicaid will, in some instances, pay for prescription eyewear to correct refractive issues. Each State decides whether or not to pay for eyewear.
State guidelines will determine how often Medicaid will pay for prescription eyewear to treat your refractive problems. The answer you get could be once a year, every two to five years, once a lifetime, or even never.
Medicaid typically doesn’t pay for contact lens prescriptions, irrespective of the vision benefits covered by the State you reside in. Contact lenses are more expensive compared to eyewear, and 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.
Medicaid sometimes pays for vision therapy (preoptic and orthotic training) because dyslexia, amblyopia (lazy eye), convergence insufficiency, and strabismus are closer to medical problems than refractive issues.
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.
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 your pupil, iris, cornea, retina, optic nerve, conjunctiva, sclera, and eyelids to prevent disorders such as keratoconus, blepharoplasty, vitrectomy, pterygium removal, among others.
Medicaid is likely to cover cataract surgery because cataracts cause your lenses to become cloudy, hindering eyesight.
In addition, your Medicaid provider may consider the operation to be medically necessary if the cataract causes vision loss past a certain eyesight measurement.
The physician will remove the faulty natural lens and replace it with a synthetic substitute. However, note that Medicaid’s least expensive alternative rule excludes most of the premium synthetic lens substitutes.
How Does Medicare Works for Eye Care?
Medicare will not cover the cost of eye exams for seniors who do not have cataracts or glaucoma. That means that 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 amount of coverage varies widely by state and, in some cases, by county.
In any case, it is typically significantly less expensive than having to pay 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 when it comes to 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 but 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.
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 years 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 to you regardless of your 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 to get a referral from a primary care Medicaid provider so that you can see a physician.
Ophthalmology appointments are paid for by the standard health component in your Medicaid coverage in the form of 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 get in touch with 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 your eye physician for assistance 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.
Federal law stipulates that Medicaid pays for visual care if you’re under 21. But if you’re above 21 years old, you have to get precertification from a physician approved by Medicaid. So, always confirm the extent of your coverage with your local Medicaid provider.
Medicaid does cover eye exams for low-income individuals. However, you do have to meet particular requirements to be eligible. Medicaid will cover you if you cannot pay for glasses or contact lenses.