The EPSDT rule from Medicaid sets a national minimum for vision care for kids under 21.
What about adult recipients over 21?
Do they also receive vision care benefits?
Adults over 21 may get vision care benefits depending on their state’s rules, insurance plan, and the needed services.
Critical Points
- The federal government mandates that all states provide vision care for treating injuries, diseases, or related symptoms. These services are medically necessary.
- Each state decides whether to offer vision care to detect and correct refractive errors, meaning the eye’s ability to focus light.
- We provide context by interpreting the state-specific standards for eyeglasses, contact lenses, eye exams, and surgeries.
Medicaid Optician Coverage
Medicaid provides uniform coverage nationwide for medically necessary adult optician services, but coverage for correcting refractive errors varies by state and plan.
It’s hard to find local opticians who accept Medicaid due to varying state policies and unclear benefits. An optician adapts eyeglasses, frames, and contact lenses for patients following ophthalmologists’ or optometrists’ prescriptions.
Optional Eyeglasses
Each state decides whether its Medicaid program will cover prescription eyeglasses for adults to correct refractive errors, and if so, how often. Optician services in this category are not medically necessary, making the benefits optional.
The main types of refractive errors are myopia (nearsightedness), hyperopia (farsightedness), presbyopia (loss of near vision with age), and astigmatism (blurry vision).
Our research shows that eyeglass benefits and replacement frequency differ by state and plan. To verify coverage, type ‘Does Medicaid cover vision for adults in …?’ into the search bar and append your state’s name.
State Rules
To ensure you have the most current information, please use the provided links to check for updates on coverage, as benefits can change. Remember, each state may have its criteria for Medicaid coverage of glasses for refractive errors. For example, in Arkansas:
- Single vision lenses must have a minimum power of either +1.00 or -0.75 sphere.
- Cylinder correction must be either -0.75 at a 90-degree axis, or +0.75 at a 180-degree axis, or the equivalent at any axis.
- Bifocal lenses for presbyopia must have a starting power of +1.00, with any subsequent changes increasing in steps of at least +0.50.”
State Plans
Please use the provided links to confirm the current vision benefits for specific plans. States often have distinct plans for different groups. In Connecticut, for instance, residents may be eligible for one of four plans, each with its vision benefits:
- Husky A, B, and D: one pair of eyeglasses every two rolling years
- Husky C: a $100 allowance for eyeglasses every two calendar years
Necessary Eyeglasses
Medicaid covers prescription eyeglasses consistently across the country following specific eye surgeries. Optician services for these cases are often medically necessary, as they treat an injury or disease.
At least two eye surgeries that treat diseases may require eyeglasses post-operation:
- A Vitrectomy addresses diabetic retinopathy, retinal detachment, macular holes, puckers, injuries, or infections.
- Cataract surgery involves replacing cloudy lenses with clear intraocular lenses to allow light rays to enter your eye properly.
Optional Contact Lenses
Each state determines if its Medicaid program provides coverage for prescription contact lenses to correct refractive errors. However, many states do not offer this benefit for adults, as eyeglasses are typically less expensive.
As a publicly funded program for low-income families, Medicaid typically covers the least expensive treatment option. On average, contact lenses have higher upfront and replacement costs than eyeglasses with basic frames.
Florida is the only state we could find covering contact lenses for adults, paying for two lenses every 365 days.
Necessary Contact Lenses
Medicaid covers contact lenses for adults uniformly nationwide to treat eye diseases and injuries. Optician services in this category are medically necessary.
For instance, Hawaii lists these conditions as qualifying for contact lenses.
- Keratoconus where corrected vision by glasses is less than 20/40.
- Corneal astigmatism in one or both eyes greater than 4.00 diopter.
- Irregular astigmatism is due to corneal imperfection, where corrected vision by glasses is less than 20/40.
- Anisometropia is due to aphakia, where the vision corrected by glasses in the non-affected eye is less than 20/50.
- Bilateral aphakia occurs when a person becomes ill while wearing spectacles or when the person’s occupation makes wearing glasses hazardous.
- Certain inflammatory conditions of the cornea for which therapeutic contact lenses are indicated with the recommendation of an ophthalmologist.
Medicaid Optometry Benefits
Medicaid coverage for adult optometry services is uniform nationwide for medically necessary care, but it varies from state to state for detecting and correcting refractive errors.
Optometrists conduct eye exams and prescribe eyeglasses or contact lenses to correct an inability to see objects clearly at a specified distance. They also test patients for various disorders.
Finding local optometrists who accept Medicaid is the most challenging task in the states that do not support adult benefits.
Optional Exams
Each state decides whether its Medicaid program will cover eye exams for adults to detect refractive errors, and if so, how often. Optometry services in this category are not medically necessary, making the benefits optional.
Our research shows that eye exam benefits and frequency differ by state and plan. To verify coverage, type ‘Does Medicaid cover vision for adults in …?’ into the search bar and append your state’s name.
Necessary Exams
Medicaid is more likely to cover adult eye exams performed by optometrists when addressing eye diseases and injuries. However, the extent of benefits may differ for initial screenings compared to follow-up testing for any of these conditions:
- Amblyopia
- Cataracts
- Diabetic Retinopathy
- Dry Eye Syndrome
- Glaucoma
- Macular Degeneration
- Ocular Nevus
- Retinal Detachment or Tear
Wellness exams are usually not considered medically necessary when the optometrist screens healthy patients for eye disorders. Each state decides whether to cover this optional vision service.
Follow-up testing for previously diagnosed eye disorders is typically medically necessary, meaning your state is more likely to cover these exams. However, while optometrists can diagnose and manage many eye conditions, they often refer patients to ophthalmologists for specialized monitoring and treatment.
Medicaid For Ophthalmology
Medicaid provides coverage for specific vision care services provided by ophthalmologists, although the extent and types of covered services vary by state.
An ophthalmologist is a licensed physician with specialized training in diagnosing and treating eye diseases and injuries, which qualifies many of their services as medically necessary.
Finding local ophthalmologists who accept Medicaid can be challenging, partly because not all eye surgeries are deemed medically necessary and thus may not be covered.
Optional Surgery
Each state decides whether its Medicaid program covers laser eye surgery performed by ophthalmologists. However, most states decline adult benefits because eyeglasses cost less to correct refractive errors.
As a publicly funded program for low-income families, Medicaid typically supports the least expensive treatment alternative. Most laser eye surgeries cost considerably more than prescription eyeglasses or contact lenses.
Payment plans might make laser eye surgery more affordable.
| Procedure | Typical Cost per Eye |
| LASIK (laser in-situ keratomileusis) | $2,000 to $4,000 |
| PRK (photorefractive keratectomy) | $1,500 to $2,000 |
| RLE (refractive lens exchange) | $3,000 to $8,000 |
| Phakic IOL (intraocular lens implant) | $3,000 to $5,000 |
Necessary Surgeries
Medicaid covers many eye surgeries performed by ophthalmologists, with coverage varying by state. These operations are considered medically necessary when treating an illness, injury, or defect threatening the sight.
Below is a partial list of eye surgeries that Medicaid may cover, depending on state-specific guidelines:
- Endoscopic Dacryocystorhinostomy (for a blocked tear duct)
- Cataract surgery (when a cloudy lens obscures eyesight)
- Blepharoplasty (if an eyelid obscures vision)
- Glaucoma surgery (to relieve intraocular pressure)
- Scleral Buckle or Pneumatic Retinopexy (for a detached retina)
- Vitrectomy (for a macular hole)
- Strabismus surgery to correct crossed eyes (esotropia), wall-eyed (exotropia), or other forms of misalignment
- Laser Vitreolysis (to remove floaters, often after cataract surgery)
- Superficial Keratectomy: Super K (for Salzmann’s nodular degeneration)
- Keratoprosthesis: K-Pro (for corneal disease)
- Pterygium removal (for surfer’s eye)
