Does Medicaid Cover Eye Exams?

A routine eye examination is an important part of your health care that should never be overlooked. This is because it can detect early symptoms of eye diseases, vision problems, and other health problems that may compromise your daily activities. 

The cost for an eye examination and prescription glasses recommended by your optometrist will seem to be costly if you do not have enough budget allocated for this kind of medical necessity. Therefore, it may be very common to ask your health insurance provider (if you are under the Medicaid program) questions like these: Does Medicaid cover exams? And then, if yes, probably you have this follow-up question in your head, Does Medicaid cover glasses?

Well, the answer to whether Medicaid covers eye exams and glasses will depend on the state where you reside since Medicaid plans vary from state-to-state. However, generally, if you are eligible, Medicaid will cover both your routine and comprehensive eye examination such as color blindness, glaucoma, and visual field test. Moreover, Medicaid will also cover your eyeglasses.

Make sure to check with your local Medicaid office to see what are the vision benefits covered under your policy.

Children and Young Adults are Automatically Covered for Vision Care

Generally, Medicaid beneficiaries who are 21 years old and below are automatically covered for vision care as part of their health insurance policy. This serves as preventive care for children so that it will lessen the risk of vision problems later in life.

Children and adolescents age 21 years and younger are eligible for vision coverage under these two programs:

1. Children’s Health Insurance Program (CHIP)

This program provides health coverage to children who are qualified both on Medicaid and individualized CHIP programs. 

Vision screenings and routine eye examinations are part of the benefits coverage and it is covered by Medicaid. Therefore, if you are eligible for CHIP benefit coverage, you may apply either through your local Medicaid office or through your local Marketplace. 

Once you have chosen your local health provider, you will enroll in their services, and then your local health provider will give you a Medicaid service card that you will use whenever you seek health care services.

2. Early and Periodic Screening, Diagnostic, and Treatment Program (EPSDT)

This program is dedicated to children under 21 years old, who are enrolled in Medicaid, which grants access to any Medicaid health care coverage benefits regardless of the amount and whether the service is covered by your plan.

Your local state is the one who is responsible to inform you regarding the EPSDT benefits and ensure that eligible children will receive their regular examination including their physical, mental, growth, and nutritional health following the scheduled timetable determined by your state, which is also known as periodicity schedule.

Therefore, the vision care benefit is covered under this program such as eye examination, free eyeglass frames, and contact lenses. However, each state has its own guideline and policy that will state how often these eye examinations should be conducted and how many times your prescription glasses or contact lenses should be replaced.  

Just because you’re an adult doesn’t mean that you’re excluded from coverage. Each state determines the level of the vision care covered for low-income adults. Remember that there are no specific federal guidelines that mandate coverage for this, so check with your local Medical office on your state’s coverage.

Which States Cover Eye Exams?

Under the Medicaid program, children and adolescents under 21 years old must receive vision screenings every check-up. If upon check-up, the doctor suspects a vision problem, the patient will be covered for further treatment and evaluation until their condition is under control.

Your state’s Medicaid program will be the one who will dictate how frequent these checkups and screening should be conducted, however, generally, it is recommended that eye checkup must be performed at least once a year to ensure the eye’s optimal health. This is because it can help to detect early potential eye or vision problems. Most importantly, it can help in identifying underlying conditions such as diabetes, glaucoma, and hypertension.

Hence, here are the basic vision care benefits covered by Medicaid that offer low-cost to free charge depending on your Medicaid policy and the state where you reside.

Routine and comprehensive eye examinations such as pupil dilation, color blindness, and other vision tests. 

Well, listed below is the state-to-state coverage for a routine eye examination

State to State Coverage For Routine Eye Examination

STATES WITHOUT COVERAGE OF EYE EXAMINATION

  • Arizona
  • Colorado
  • Delaware
  • Florida
  • Georgia
  • Idaho
  • Kentucky
  • Louisiana
  • North Carolina
  • Oklahoma
  • South Carolina
  • Tennessee

STATES THAT CONDUCT EYE EXAMINATION ONCE ANNUALLY

  • Alaska
  • Connecticut
  • Illinois
  • Iowa
  • Missouri
  • Nevada
  • New Hampshire
  • Texas
  • Utah
STATES THAT CONDUCT EYE EXAMINATION ONCE EVERY TWO YEARS
  • Arkansas
  • California
  • Hawaii
  • Indiana
  • Maryland
  • Massachusetts
  • Michigan
  • Montana
  • Nebraska
  • New York
  • North Dakota
  • Ohio
  • Oregon
  • Rhode Island
  • Vermont
  • Virginia
  • Washington
STATES THAT CONDUCT EYE EXAMINATION ONCE EVERY THREE YEARS OR MORE
  • Alabama
  • Kansas
  • Maine
  • Mississippi
  • New Mexico
  • West Virginia

Which states’ Medicaid covers Prescription Glasses? 

Eyeglasses, which includes frames, repairs, replacement, and fittings. If you are 21 years old and below, you can ask for replacement twice per year, if your glasses were lost, stolen, or broken. Otherwise, it was stated once a year only.

However, some states do not provide coverage for prescription glasses, especially to pregnant women.

STATES THAT DO NOT COVER PRESCRIPTION GLASSES
  • California
  • Oregon
  • Utah

Contact lenses will not be covered by Medicaid if it is requested for cosmetic purposes. For example, to replace your eyeglasses to improve your physical appearance. However,  if they are deemed to be medically necessary, or if they are prescribed by your optometrist, your plan may cover them.

Here are some of the conditions where contact lenses may be covered:

  • Aphakia – the absence of the lens of the eyes after undergoing a cataract surgery
  • Anisometropia – your eyes have unequal refractive powers 
  • Myopia

Bifocal and trifocal are covered. If bifocal does not work or you, you may acquire two pairs of single vision glasses. On the other hand, oversized lenses and multifocal lenses are not covered. You may pay for the additional cost if you want to upgrade your standard lenses.

Remember: Medicaid covers only standard frames, glasses, and contact lenses. Premium frames or specialty lenses are not covered, but you may foot the bill for the additional cost.

Medicaid usually covers and approves one pair of eyeglasses every year. In some special cases, you may ask for additional prescription glasses, if it is considered to be medically necessary.

To use your coverage, you are required to seek medical assistance from only approved Medicaid optometrist and ophthalmologist.

How to Find Eye Doctors that Take Medicaid?

To find an eye doctor that takes Medicaid, you need to look at your insurance card to know the participating vision care providers accredited by your plan. But, most likely, your local agency may assign you to any of these four managed care facilities:

However, some might opt to vision centers to seek medical eye assistance. Therefore, you might be wondering, does Walmart eye center take Medicaid? Well, the answer is yes, they take Medicaid and other insurance plans such as Aetna, Amerigroup, Blue Cross, Cigna, Medicare, and others. If you want to see the full list of accredited health care plans of Walmart Eye Center, you may check this site.

Meanwhile, upon undergoing several eye examinations, you have been diagnosed with a serious eye problem. Are serious eye problems still covered by Medicaid as part of their vision care benefits? Well, you may read below to find out.

Are Serious Eye Problems Covered by Medicaid?

If you have a serious eye problem such as cataracts, glaucoma, or detached retinas, you need to see an ophthalmologist. An ophthalmologist is a kind of medical doctor that specializes in vision care such as performing eye surgeries, prescribing ophthalmic medications, diagnosing, and treating eye diseases.

However, in order to cover the medical bill for eye surgery, it must be deemed medically necessary. One very good example of an eye surgery that Medicaid will most likely cover is the cataract surgery. This is a procedure wherein they remove the affected lens of your eyes and then replace it with an artificial lens.

Aside from cataract surgery, here are other eye surgeries that Medicaid will most likely cover. You may call your state’s Medicaid office to check the list of eye surgeries that they cover. Also, make sure to ask if the insurance company dealing with your plan requires prior authorization.

  • Trabeculectomy – lower the intraocular pressure (IOP) inside the eye in patients with glaucoma
  • Pneumatic Retinopexy – repair certain types of retinal detachments
  • Pterygium surgery – removal of the abnormal tissue from the cornea and sclera of the eye
  • Dacryocystorhinostomy – create a new tear drain between your eye and nose, if your tear duct has become blocked.

Vitrectomy – removal, and replacement of all the fluids from the eye to treat the eye’s retina and vitreous.

Robert Taylor Smith
 

Robert's motto is to start "with the end in mind." He married the love of his life in December 2016. Together with his wife Tanya, they're putting the building blocks in place for their eventual retirement. He's taken over the mantle at retirementsavvy.net and hopes to share his experiences with our readers.

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