Does Medicaid Cover Vision? – Overview
The answer as to whether Medicare 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 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. The primary objective of regular vision care is to make sure that you have the best eyesight possible.
Under Medicaid, vision care comprises eye exams, eyewear, 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 which Medicaid approves for coverage, but they aren’t always necessary. For instance, eyewear and optometry fall under this category, meaning that the Medicaid coverage will vary state-by-state.
Which Vision Care Procedures Does Medicaid Pay for?
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 exams 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 any eye disorders that have 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 lenses 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 cover.
Prior to 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 Much Do You Pay Out-Of-Pocket for Vision with A Medicaid Plan?
For vision care, expect to be liable for co-payments of between 0 to 15 USD depending on the US State you reside in. Most States have different co-payments for kids and adults.
Depending on your State, you could pay a co-payment for eyewear, or there could be a separate charge for them. Check on your State’s Medicaid vision benefits so that you can confirm what’s covered and the expenses you are liable to pay.
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 cover 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.
To sum it all up, Federal law stipulates that Medicaid pays for your visual care if you’re under 21 years. But if you’re above 21 years, you have to get precertification from a physician approved by Medicaid. So always confirm the extent of your coverage with your local Medicaid provider.