Last Updated on April 24, 2022 by Anne-Sophie Reinhardt
Medicaid is a popular way for Americans to access healthcare services. So, does Medicaid cover cataract surgery?
In short, vision care coverage, including cataract surgery, is an optional benefit, and coverage varies from state to state.
It can include hildren and young adults under 21 who are eligible for Medicaid vision benefits are included. Vision benefits for adults, however, are not guaranteed. Vision benefits for adults include eye exams, wearables, and other medically required procedures.
Even if you have Medicaid coverage, cataract surgery can be costly. It will all depend on your out-of-pocket costs under your Medicaid plan. Do not worry, there are private insurance companies that provide financial assistance to those who qualify for Medicaid for cataract surgery.
Medicaid and Cataract Surgery
Commonly, adults aged 60 and over have cataract surgery to correct vision problems caused by cloudy lenses.
Medicaid offers some benefits that can help with vision impairment such as eye exams and eyewear, as well as cataract surgery. These benefits are available to children, adults, disabled persons, pregnant women, and those below 65 years of age.
Each state determines which vision benefits are in their plan. Medicaid covers eye exams for children and will pay for any additional costs if the checkup uncovers issues like cataracts.
However, Medicaid will not cover eye exams for adults if performed in a hospital as part of routine health checks. Besides, Medicaid will cover treatment, if an eye condition has a doctor’s diagnosis and is a primary concern.
How Can You Confirm If Medicaid Will Pay for Your Cataract Surgery?
You can contact your State Medicaid office to find out more about your Medicaid plan. In this instance, if it will pay for cataract surgery.
They can assist you with:
- Medicaid eligibility
- Plan services
- Liens and third-party insurance liability
- Medicaid claims
- The replacement of a lost Medicaid card
- How to find Medicaid-approved doctors near you
- Status of your Medicaid application
Which Cataract Surgery Benefits Do You Receive from Medicaid?
People of age 21 and above can access the following:
- Allowance for eyewear (one frame, two lenses)
- Contact lenses that treat aphakia or cataracts.
- A recommendation from the PCP for specialist eye examinations.
Besides, children and young adults under 21 can have access to:
- Routine vision exams are usually done twice per year.
- Allowance for eyewear (one frame, two lenses).
- Each year, you will receive two frames and four lenses. If the glasses are medically necessary (e.g. if they change prescription), coverage will apply for the second pair. Moreover, for special reasons, exceptions to the limits may get approval.
- If contact lenses or eyewear are lost or damaged, they can be replaced. However, the service provider must provide written documentation to show the Medicaid office that the prescription has changed.
- Any other vision or eyewear deemed medically essential. The Medicaid office must receive written documentation to prove the need for service.
How Much Does a Cataract Surgery Cost?
Cataract surgery is expensive. The cost of the lenses will also affect the final price. Toric lenses are around 1500 USD per eye, while specialty lenses can be costly at 3000 USD per eye.
Remember that Medicaid will cover the least expensive option if your plan covers cataract surgery. If you choose expensive lenses, they may be excluded from your insurance plan. So, you may have to pay out-of-pocket.
If you are an adult eligible for Medicare instead of Medicaid, 20% of your expenses for corrective lenses and Original Medicare deductibles will be covered. You will have to pay out-of-pocket for expensive or upgraded eyewear and contact lenses.
Adults eligible for Medicare and Medicaid can use both benefits. Medicare would be the primary coverage for the surgery. Medicaid would take care of other expenses uncovered by Medicare. 3rd party insurance, if available, would also be there to fill the gaps left by the primary insurance plan.
When you sign up for private US health insurance companies such as United Healthcare and Blue Shield, you will receive supplemental vision benefits. If you have the means to pay for 3rd-party health insurance, this will help reduce your out-of-pocket expenses. Also, as we know, cataract surgery is costly.
Which Factors Affect the Cost of Cataract Surgery?
These are the key factors that affect the price of cataract surgery.
- What type of intraocular lenses (IOLs) are in your eyes.
- The surgeon or ophthalmologist charges the cost of the procedure.
- If the cataract surgery can be done, outpatient.
- If you have to remain in the hospital following surgery.
- Pre- and post-surgery doctor appointments, medication.
- Regional pricing inconsistencies.
These variables can impact the cost of your cataract surgery, but your Medicaid plan is the main factor that will determine your out of pocket expenses.
To summarise, Medicaid could cover your cataract surgery if it falls within the optional benefits. Besides, the state you are in would be the one to determine the benefits.
Medicaid will only cover a small portion of the cost of regular cataract surgery. You will still have to pay some out-of-pocket costs for cataract surgery. To find out more about the coverage of your vision care plan, you can contact your local Medicaid office.