The answer to whether Medicaid covers vision care for adults depends on the reason for the service, and the state where the patient lives.
Medicaid typically pays for medically necessary eye care in all fifty states. Medically necessary care diagnoses or treats an illness, injury, condition, disease, or its symptoms.
Exams, contact lenses, and eyeglasses to diagnose and correct refractive vision errors do not fit the definition. However, some states cover these services anyway – and some do not – or with limitations.
Therefore, you need to apply both of these factors together before searching for an eye doctor that accepts Medicaid in your local area.
When Medicaid Covers Optometry
The criteria for when Medicaid covers optometry for adults hinge on the state where you live, and medical necessity. An optometrist is a non-medical practitioner who performs eye exams and vision tests, detects orbital abnormalities, and prescribes corrective lenses and medications.
Most services provided by an optometrist are not medically necessary and fall under the vision insurance plan umbrella. Medicaid is always a healthcare plan. Therefore, any additional vision coverage depends on what each state decides to offer its low-income population.
Medicaid pays for medically necessary eye exams for adults performed by optometrists in all fifty states. However, the coverage for routine basic vision tests depends on where you live. The frequency of examinations is also a significant factor.
Medicaid pays for dental and vision care for adults when medically necessary. Needed care could include follow-up eye exams and tests for a pre-existing illness, or a visit prompted by disease-related symptoms. The optometrist may need to diagnose, treat, and monitor the progression one of these most common maladies that might threaten your vision – or others.
- Diabetic Retinopathy
- Dry Eye Syndrome
- Macular Degeneration
- Retinal Detachment or Tear
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.
For example, Pennsylvania allows two vision exams each year. Meanwhile, New Jersey pays for tests when the patient meets visual acuity criteria. The other states fall into one of four neat categories.
Once Every 2 Years
|New York||North Dakota||Ohio|
Once Every 3 Years +
|Mississippi||New Mexico||West Virginia|
Medicaid pays for prescription eyeglasses and basic frames following the pattern for medically necessary and refractive exams noted above. For example, your plan is more likely to pay for adults when correcting vision due to an accident or disease in all fifty states. On the other hand, the coverage for prescription eyeglasses to correct simple refractive errors varies by state.
Some states do not provide coverage for prescription eyeglasses at all. Plus, three states restrict the eyeglass benefit to pregnant women or people fitting other limited categories.
Meanwhile, others will pay for one pair of glasses based on frequency: one year, two years, three years, etc. Then, others will require a minimum diopter correction from the previous pair.
Medicaid typically does not cover contact lenses for adults when requested for cosmetic reasons – to improve appearance by replacing eyeglasses. However, your plan is more likely to include 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 – a faulty refractive ability
- Keratoconus – cornea bulges outward
- Keratoconjunctivitis Sicca – dry eye
When Medicaid Covers Ophthalmology
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.
Medicaid is more likely to deem the treatment of disease and injury as medically necessary, and honor claims for these services. However, you may have to pay out-of-pocket for any procedures designed to improve vision or appearance.
Medicaid rarely pays for LASIK eye surgery and other operations intended to correct refractive vision errors. Refractive eye surgeries performed by ophthalmologists are not medically necessary. They do not treat an injury or disease, and the patient can address the issue via cheaper prescription eyeglasses or contacts.
You will probably have to pay out-of-pocket if your ophthalmologist recommends any of these cosmetic eye surgeries. Financing programs are the primary alternative for many patients.
- Laser In-Situ Keratomileusis (LASIK)
- Laser Epithelial Keratomileusis (LASEK)
- Photorefractive Keratectomy (PRK)
- Radial Keratotomy (RK)
- Epipolar Laser In Situ Keratomileusis (Epi-LASIK)
- Refractive Lens Exchange (RLE)
Medicaid is most likely to cover cataract and other medically necessary eye surgeries performed by an ophthalmologist. 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)
Check with your hospital regarding any financial help they offer to low-income patients who cannot afford an expensive surgery.
Finding Eye Doctors That Accept Medicaid
Finding eye doctors that accept Medicaid in your local area begins by looking at your insurance card. A private company will manage the plan and publish an online directory of participating providers. Locate the online directory, input your zip code, and plan name. The online application will output a list.
However, the vision service that you need and the type of coverage combine to determine whether the eye doctor will accept Medicaid patients for a specific treatment or reason.
- As noted above, each state has unique parameters, whether it will pay for exams, glasses, contacts, and surgeries.
- Your state agency can assign you to one of four different managed care entities with varying benefit levels.
- Managed Care Organizations (MCOs): comprehensive
- Primary Care Case Management (PCCM)
- Prepaid Inpatient Health Plan (PIHP): limited
- Prepaid Ambulatory Health Plan (PAHP): most limited
When searching for vision centers that accept Medicaid patients, you must be most alert to the rules in your state and the type of coverage that you have. Vision centers primarily staff with optometrists who perform refractive eye exams and prescribe contacts and glasses, and opticians who fit devices to correct eyesight.
As noted above, the state variations are most sensitive to refractive exams and corrective lenses because these services are not medically necessary. Therefore, verify the timing rules for your plan before booking an appointment at the vision center.
Vision centers found at large retailers such as Walmart and Target typically want to accept Medicaid as their stores cater to low-income shoppers. Of course, the payment level at a Walmart in Georgia (no coverage for exams or glasses) will be very different from one in Texas (annual eye test and spectacles), and so on.
Patients are far more likely to find ophthalmologists who accept Medicaid because many of their services are medically necessary. For example, patients in all 50 states should be able to locate a participating ophthalmologist to perform cataracts or glaucoma surgery or treat diseases of the eye.
Ophthalmologists also perform refractive eye exams and prescribe glasses and contacts. However, just because Medicaid will pay for the medically necessary surgeries and treatments, does not mean that it will cover these other vision services that correct refractive errors in every state.