The answer to whether Medicaid covers adult eye care depends on the medical reason, the state where the patient lives, and whether an optometrist or ophthalmologist provides the service.

Medicaid is more likely to pay for medically necessary vision care in all fifty states.

It is less likely to pay for exams, eyeglasses, contact lenses, and surgeries that detect and correct refractive errors – when the eye cannot focus light properly.

Optometrist Exam & Corrective Lens and Medicaid

The criteria for when Medicaid covers optometrist exams and corrective lenses for adults hinge on the state where you live, and medical necessity. An optometrist is not a medical doctor. An optometrist performs eye exams and vision tests, detects orbital abnormalities, and prescribes corrective lenses and medications.

Medical loans can fill the gap in the common cases where you must pay for vision care out-of-pocket.

The optometrist services associated with diagnosing and correcting refractive vision problems are not medically necessary. However, the portions of services that address diseases of the eyes are necessary and covered. In addition, some states expand coverage for vision correction, but many do not. Therefore, you must break down coverage for exams, prescription eyeglasses, and contacts separately.

Eye Exams

Medicaid pays for medically necessary eye exams for adults performed by optometrists in all fifty states. The coverage for basic vision tests depends on where you live. The frequency of exams is also a major factor.

Medically Necessary

Medicaid pays for dental and vision care for adults when medically necessary. This could include follow-up eye exams and tests for a pre-existing disease, or a visit prompted by symptoms. The optometrist may need to diagnose, treat, and monitor the progression one of these most common diseases that might threaten your vision – or others.

  • Amblyopia
  • Cataracts
  • Diabetic Retinopathy
  • Dry Eye Syndrome
  • Glaucoma
  • Macular Degeneration
  • Retinal Detachment or Tear

Vision Exams

Refraction vision exams test the adult patient’s ability to see an object at a specified distance. In many states, Medicaid will extend coverage for refractive tests with limits based on frequency.

Pennsylvania allows two vision exams each year. New Jersey pays for services when the patient meets visual acuity criteria. The other states fall into one of four neat categories.

No Coverage

ArizonaColoradoDelaware
FloridaGeorgiaIdaho
KentuckyLouisianaNorth Carolina
OklahomaSouth CarolinaTennessee

Once Annually

AlaskaConnecticutIllinois
IowaMissouriNevada
New HampshireTexasUtah

Once Every 2 Years

ArkansasCaliforniaHawaii
IndianaMarylandMassachusetts
MichiganMontanaNebraska
New YorkNorth DakotaOhio
OregonRhode IslandVermont
VirginiaWashington

Once Every 3 Years +

AlabamaKansasMaine
MississippiNew MexicoWest Virginia

Prescription Eyeglasses

Medicaid pays for prescription eyeglasses and basic frames following a pattern similar to medically necessary and refractive exams. The plan is more likely to pay for adults when correcting vision due to an accident or disease.

Medicaid pays for prescription eyeglasses to correct simple refractive errors following a similar pattern to exams. Some states do not provide coverage. Others will pay for one pair of glasses based on frequency: one year, two years, three years, etc. Others will require a minimum diopter correction from the previous pair.

Three states restrict the eyeglass benefit to pregnant women or other limited categories. They are California, Oregon, and Utah.

Contact Lenses

Medicaid does not cover contact lenses for adults when requested for cosmetic reasons – to improve appearance. However, your plan is more likely to cover medically necessary contact lenses when needed to correct vision problems brought on by accidents or diseases. Below is a partial list of conditions a plan might include.

  • Aphakia – after cataract surgery
  • Anisometropia – two eyes have unequal refractive power
  • High Ametropia – faulty refractive ability
  • Keratoconus – cornea bulges outward
  • Keratoconjunctivitis Sicca – dry eye

Ophthalmology Appointments Medicaid Coverage

The criteria for when Medicaid covers ophthalmology services for adults has less to do with what state you live in, and more to do with the medical reasons behind the appointment. An ophthalmologist is a medical doctor specializing in vision care. An ophthalmologist diagnoses and treats eye diseases and injuries, and performs surgery.

Because ophthalmologists treat diseases and injuries, Medicaid is more likely to deem the treatments as medically necessary. However, you will have to pay out-of-pocket for any procedures designed to improve vision or appearance.

Surgery to Improve Vision

Medicaid will not pay for eye surgeries intended to improve vision for an adult. A pair of prescription eyeglasses will suffice. This includes corrective operations for myopia (nearsightedness), hyperopia (farsightedness), or astigmatism – or just to improve reading.

These procedures work by altering the way that your cornea refracts light. Refractive eye surgeries are not medically necessary. They do not treat an injury or disease.

Financing programs can provide the cash needed to pay your ophthalmologist to correct your vision this way. You will probably have to pay out-of-pocket if your ophthalmologist recommends any of these eye surgeries.

  • Laser In-Situ Keratomileusis (LASIK)
  • Laser Epithelial Keratomileusis (LASEK)
  • Photorefractive Keratectomy (PRK)
  • Radial Keratotomy (RK)
  • Epipolis Laser In Situ Keratomileusis (Epi-LASIK)
  • Refractive Lens Exchange (RLE)

Cosmetic Surgical Procedures

Medicaid will pay for any cosmetic eye surgeries that restore normal appearance after a disfiguring disease or accident to the adult. Verify this with your plan first. It should classify restoration of appearance as medically necessary.

Medicaid will not pay for cosmetic eye surgery when you are enhancing normal appearance. You will probably have to pay out-of-pocket for these two common cosmetic procedures.

  • Blepharoplasty (eyelid procedure to remove bags of excess skin or make the eyes look bigger)
  • Stroma eye color operation (turn brown eyes to blue)

Medically Necessary Surgeries

Medicaid is more likely to pay for eye surgeries deemed medically necessary for the adult patient. These operations prevent or treat illnesses and diseases such as Diabetes, Grave’s Disease, Keratoconus, Multiple Sclerosis, and others. Other procedures may 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 more likely to cover in all 50 states. Check with the company administering your plan for a preapproval. This website does not adjudicate claims, nor are we the final authority on the topic.

  • Endoscopic Dacryocystorhinostomy (blocked tear duct)
  • Cataracts (blurry 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)

Sources

Posted