Last Updated on April 24, 2022 by Anne-Sophie Reinhardt
Does Medicaid Cover Vision? You may ask!
The reason you need vision care and your age will determine whether Medicare will cover it. It also depends on where you live in the United States because Medicaid benefits depend on state-by-state.
Medicaid will cover vision care for people under 21 years of age in the United States if the EPSDT (Early, Periodic Screening, Diagnostic, Treatment) plan cover them. Medicaid will also cover the cost of diagnosing and treating vision problems.
For those over 21, things can get complicated because every state decides whether or not Medicaid will cover their vision care. This includes eye exams, therapy, contact lenses, eyewear, and eyewear. Medicaid will only cover medically necessary eye procedures.
What Is Vision Care?
Vision care refers to a variety of procedures that are involved in maintaining healthy, functional eyes. Regular vision care has one primary goal: to ensure that you have clear, sharp eyesight. This also includes eye exams, eyewear and eye surgery under Medicaid. These visual benefits include two parts:
Mandatory Medicaid Vision Benefits
Federal law requires all US State Medicaid plans to provide coverage for certain benefits. This means that Medicaid will pay 100% for eye exams and eye surgeries if the Medicaid program covers them.
Optional Medicaid Vision Benefits
These optional vision benefits can be approved by Medicaid for coverage but are not always required. Optometry and eyewear are examples of this category. This means that Medicaid coverage will differ from one state to the next.
Which Vision Care Procedures Does Medicaid Pay for?
The guidelines in your State will determine if Medicaid will cover your optometry exam. Optometry is a doctor who diagnoses and corrects refractive problems. This refers to the inability of seeing an item at a specified distance.
Each state decides whether to pay for refractive or optometry eye exams and how often you should have them.
Medicaid will cover ophthalmology examinations in all US States, regardless of whether you have vision benefits. Ophthalmology exams can diagnose and treat eye conditions that may have a medical basis. Medicaid pays for some ophthalmology tests, including:
- Diabetic Retinopathy
- Macular degeneration.
- Dry eye syndrome.
- Retinal detachment.
Prescription eyewear for correcting refractive problems will be covered by Medicaid in certain instances. Each state decides if or not it will pay for eyewear.
The state guidelines will dictate how often Medicaid will cover prescription eyewear for your refractive issues. You could get an answer once a month, once every two to five, once a life time, or none at all.
Medicaid doesn’t usually pay for contact lenses prescriptions, regardless of whether or not you have vision benefits. Contact lenses can be more costly than eyewear. Moreover, people often use them for cosmetic reasons.
They are not in Medicaid’s benefits. There are, however, some instances where Medicaid covers contact lenses. These include:
- Contact lenses are necessary when the patient is unable to wear glasses. If a patient is missing an ear or has a deformed nose.
- A doctor will consider contact lenses to be medically necessary if they are intended as prosthetic devices.
Medicaid can sometimes pay for vision therapy (preoptic or orthotic training), because convergence insufficiency, dyslexia, amblyopia, and strabismus are more closely related to medical issues than refractive problems.
Although your health insurance may cover the Medicaid coverage, it isn’t easy to find a visual therapist that accepts Medicaid. Precertification is a must before you can start your therapy sessions. Your Medicaid provider should write a letter of medical necessity.
Medicaid can cover eye surgery under the health insurance component. This means that there are uniform requirements across all US states for medically necessary eye surgeries. Eye surgery repairs injuries to the pupil, iris and retina. Surgeries like these prevent disorders such as keratoconus, blepharoplasty, vitrectomy, pterygium removal, among others.
Because cataracts can cloud your vision, Medicaid will likely cover the procedure. If the cataract results in vision loss beyond a certain eyesight measurement, your Medicaid provider might consider the operation medically necessary.
The doctor will replace the defective natural lens with a synthetic one. Note that Medicaid’s lowest-priced alternative rule does not cover most premium synthetic lens substitutes.
How Much Do You Pay Out-Of-Pocket for Vision with A Medicaid Plan?
You will be responsible for co-payments for vision care. These payments can vary depending on where you live in the United States. Besides, many states have different copayments for adults and kids.
However, you may have to pay a copayment or additional charges depending on where you live. You can verify your State’s Medicaid vision benefits to see what is covered and what you are responsible for.
How Can You Take Advantage of Medicaid’s Vision Benefits?
You will need to request a referral from your primary care Medicaid provider if you are eligible for Medicaid visual benefits. Besides, your Medicaid standard health coverage covers ophthalmology visits. This includes care from a specialist physician. You can also take advantage of Medicaid’s vision benefits by seeing an approved ophthalmologist.
The Benefits Gov website will help you connect with the nearest Medicaid outlet. The page will allow you to filter outlets by state and subcategory (Medicaid) to locate the nearest Medicaid outlet. Your eye doctor can also help you use your Medicaid vision benefits, but some doctors won’t accept Medicaid coverage. However, they may refer you to another provider that does take Medicaid coverage.
The federal law states that Medicaid will pay for your vision care under 21 years old. So, if you are over 21 years old, you will need to obtain precertification from a Medicaid-approved physician. Always confirm your coverage with your local Medicaid provider.