The answer to whether Medicaid covers vision depends on the reason for the care, the state where the person lives, and the patient’s age.
Medicaid pays for eye care for children under 21 throughout the country under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
However, things become murky for adults over 21 as each state decides whether and how often to pay for vision care: exams, eyeglasses, contact lenses, and therapy.
On the other hand, Medicaid pays for many eye surgeries across the country when medically necessary. In these cases, the health insurance component makes the rules.
When Medicaid Covers Eye Exams
Medicaid sometimes covers eye exams for adults. The reasons for the visual testing and your state of residence determine whether your plan will honor claims and how frequently.
Finding a local eye doctor that accepts Medicaid could prove challenging due to the low reimbursement rates and varying levels of coverage.
- Medicaid acts as health insurance with relatively uniform benefits across the country for medically necessary eye care.
- Medicaid acts as vision insurance with widely varying benefits state-by-state when measuring refractive errors.
Optometry Exams
The state rules where you live determine whether Medicaid will cover optometry exams and how often. An optometrist specializes in diagnosing and treating refractive errors: the inability to see an object at a specified distance.
Each state determines whether to support refractive eye exams and the frequency of optometry appointments. The charts depict benefits for adults (over 21) who have not had previous eye surgery (see below) or disease.
No Coverage
Once Annually
| Alaska | Arkansas | Florida |
| Georgia | Idaho | Illinois |
| Iowa | Kentucky | Michigan |
| Nevada | New Hampshire | North Dakota |
| South Carolina | South Dakota | Utah |
Every Two Years
| California | Connecticut | Indiana |
| Maine | Maryland | Massachusetts |
| Minnesota | Missouri | Montana |
| Nebraska | New York | North Carolina |
| Ohio | Pennsylvania | Rhode Island |
| Vermont | Wisconsin |
Three Years or More
| Alabama: 3 | Kansas: 4 | Mississippi: 5 |
| New Mexico: 3 |
Ophthalmology Exams
Medicaid is likely to cover ophthalmology exams across the country under the health insurance component for medically necessary conditions, regardless of the vision benefits supported in your state.
Medicaid pays for dental and vision care for adults when medically necessary: the service diagnoses or treats an injury, illness, or its symptoms.
An ophthalmologist is a physician who specializes in the diagnosis and treatment of eye disorders with a medical cause. Once diagnosed with one of these conditions, your plan might pay for annual exams rather than follow the schedule noted above.
- Amblyopia
- Cataracts
- Diabetic Retinopathy
- Dry Eye Syndrome
- Glaucoma
- Macular Degeneration
- Ocular Nevis
- Retinal Detachment or Tear
When Medicaid Covers Vision Care
Medicaid sometimes covers vision care: prescription eyewear (glasses, contact lenses, frames, therapy) to improve eyesight. However, the rules in your state and the reason (refractive errors versus medically necessary) shed light on the benefits you might expect.
Eye Glasses
Medicaid sometimes covers prescription eyeglasses to correct refractive errors. Once again, your state’s rules determine benefits and frequency.
Frequency
The rules in your state determine how often Medicaid will pay for prescription eyeglasses to correct refractive errors. Your answer could be: never, once per year, every two to five years, or once per lifetime.
In most cases, the frequency for updated lenses follows that same schedule as exams (see above). However, a handful of states have different rules for glasses.[1]
| How Often | |||
|---|---|---|---|
| Never | Maryland | ||
| One Year | Kansas | Michigan | New Mexico |
| Two Years | Illinois | Kentucky | North Dakota |
| Five Years | Indiana | ||
| Once per Lifetime | Maine | Nebraska | New Hampshire |
Frames
Your Medicaid plan might pay for eyeglass frames following specific parameters, provided your state supports vision benefits.
- Replacement frames needed for a justifiable medical reason
- Child’s growth
- Metal allergy
- Standard frames representing the least expensive alternative
- Non-standard frames rarely qualify
- Sunglasses
- Safety glasses
- Deluxe frames (cosmetic)
Diabetics
Medicaid could pay for eyeglasses for diabetics across the country for three reasons, regardless of whether your state supports vision benefits.
- Diabetes is a medical condition covered under the health insurance module
- The eyeglasses magnify and filter light rather than correct refractive errors
- The devices could be the least expensive treatment alternative
Have your ophthalmologist put together a letter of medical necessity describing how your diabetic retinopathy affects your ability to see. You will need precertification from the carrier.
Contact Lenses
Medicaid typically does not cover prescription contact lenses for adults regardless of whether your state supports vision benefits. Contact lenses are a more expensive treatment for refractive errors than eyeglasses, and patients often request them for cosmetic reasons.
Therefore, Medicaid rarely includes benefits for these reasons. However, every rule has exceptions.
- Contact lenses when needed because the patient cannot wear eyeglasses. For example, patients with missing ears or defective noses.
- Contact lenses that act as prosthetic devices are sometimes medically necessary and fall under the health insurance section. Therefore, Medicaid might pay for contact lenses needed for any of these reasons. [2]
- Aphakia – after cataract surgery
- Anisometropia – two eyes have unequal refractive power
- High Ametropia – a faulty refractive ability
- Keratoconus – cornea bulges outward
- Keratoconjunctivitis Sicca – dry eye
- A few states cover contact lenses for refractive errors alone.
Vision Therapy
Medicaid sometimes covers vision therapy (orthoptic and pleoptic training) because lazy eye (amblyopia), strabismus, dyslexia, and convergence insufficiency are closer to medical issues than refractive errors.
Therefore, the health insurance element might pay for vision therapy, although the low reimbursement rates might make it hard to find a provider accepting Medicaid.
Have your provider write a letter of medical necessity. You will need precertification before beginning any sessions.
Research the parameters in your state as some explicitly address vision therapy, although most do not.
When Medicaid Covers Eye Surgery
Medicaid sometimes covers elective eye surgeries designed to improve vision. An ophthalmologist can treat a wide range of covered illnesses and injuries that affect your sight.
Medicaid is likely to pay for an elective operation that meets two criteria.
- It is the least costly treatment alternative
- It has a medically necessary reason
Necessary Procedures
Medicaid is likely to cover an ophthalmologist’s eye surgeries under the health insurance module, which means uniform parameters across the country for medically necessary procedures.
- An operation prevents or treats illnesses and their symptoms such as Diabetes, Grave’s Disease, Keratoconus, Multiple Sclerosis, and others.
- An operation to repair injuries to your iris, pupil, sclera, retina, optic nerve, cornea, conjunctiva, lids, etc.
Below is a partial list of eye surgeries that Medicaid is likely to cover in all 50 states when your provider can establish medical necessity and obtain precertification.
- Endoscopic Dacryocystorhinostomy (blocked tear duct)
- Cataract (cloudy lens obscures eyesight)
- Blepharoplasty (eyelid obscures vision)
- Glaucoma (to relieve pressure)
- Scleral Buckle or Pneumatic Retinopexy (detached retina)
- Vitrectomy (macular hole)
- Strabismus (crossed eyed, wall-eyed, or lazy eye)
- Laser Vitreolysis (remove floaters after cataracts operation)
- Superficial Keratectomy: Super K (Salzmann’s nodular degeneration)
- Keratoprosthesis: K-Pro (corneal disease)
- Pterygium removal (surfers eye)
LASIK
Medicaid rarely pays for Laser Eye Surgery such as LASIK because a cheaper, less invasive solution exists to correct refractive vision errors: prescription eyeglasses and contact lenses.
Laser In-Situ Keratomileusis (LASIK) is never medically necessary because cheaper alternatives exist that correct vision. The same holds for similar operations that address refractive errors rather than health problems.
- Laser Epithelial Keratomileusis (LASEK)
- Photorefractive Keratectomy (PRK)
- Radial Keratotomy (RK)
- Epipolar Laser In Situ Keratomileusis (Epi-LASIK)
- Refractive Lens Exchange (RLE)
Cataract
Medicaid is more likely to pay for cataract surgery because the lens has become cloudy, which obscures eyesight. Your plan administrator could deem the procedure as medically necessary if the cataract causes vision loss beyond a specific measurement.
The ophthalmologist removes the natural defective lens from the eye and replaces it with an artificial substitute. However, the least costly alternative rule eliminates many of the premium options for a cataract replacement lens.[3]
- Monofocal intraocular lenses are the least expensive
- Pricier upgrades are typically not included
- Toric lenses (astigmatism-correcting)
- Symfony EDOF (extended-depth-of-focus)
- PanOptix trifocal lens
Citations:
[2] Aetna Medical Clinical Policy Bulletin