Eye exams are a crucial part of preserving your eyesight. However, navigating the financial side of vision care can be daunting at first—especially when you’re trying to figure out which services are covered by Medicaid and Medicare.
For some adults, Medicaid may cover eye exams if a healthcare professional deems the exam to be a medical necessity. Meanwhile, some Medicare plans cover eye exams while others don’t. If you’re unsure as to whether your insurance plan will cover your eye exam, contact your optometrist or your insurance provider to clarify.
What Does Medicaid Cover?
Medicaid is a joint federal and state program designed to make healthcare more accessible to eligible low-income families and individuals. In Texas, Medicaid offers a range of health services aimed at providing comprehensive care to residents.
To qualify for Medicaid in Texas, you typically need to fall into one of several eligibility groups, which include:
- Low-Income Families
- Pregnant Women
- Individuals Receiving Supplemental Security Income (SSI)
- Individuals Receiving Mandatory State Supplements
This eligibility is determined by your income, household size, and several other factors. Specific requirements can vary depending on each category.
Services Covered by Medicaid
Medicaid in Texas offers a range of services, including but not limited to:
- Doctor visits
- Hospital stays
- Prescription medications
- Preventive care, such as vaccines and screenings
- Mental health services
It’s important to note that some of these services may vary depending on your location and specific plan.
Does Medicaid Cover Eye Exams?
When it comes to eye care, Medicaid is more specific. Typically, Medicaid will cover eye exams for children aged 20 and younger through a program called the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).
- 1 annual eye exam
- Eyewear deemed medically necessary from a limited selection
- Replacement eyeglasses once every 2 years (unless the previous pair has been destroyed or lost, in which case repairs and replacement are covered)
For adults, Medicaid coverage becomes more complex. The default Medicaid plan does not cover eye exams unless it’s a medical emergency, so if you want your eye care services covered, you need to apply for a program called STAR*PLUS.
The STAR*PLUS plan can be added to both Medicaid and Medicare, and covers:
- 1 routine eye exam per year for adults aged 21 and older
- Up to $300 towards eyeglasses or contact lenses
There are several versions of the STAR*PLUS plan, each with specific add-ons and requirements.
What Does Medicare Cover?
Medicare is a federal health insurance program specifically designed to support older adults over the age of 65, though it can sometimes cover adults under 65 with specific medical conditions.
Usually, coverage under this plan is partial. Additional tests and screenings may charge a fee not covered by Medicare.
Medicare is broken down into several different parts, each with unique coverage.
Medicare Part A
This plan covers standard inpatient hospital care, along with:
- Skilled nursing support
- Some home healthcare
- Hospice care
Medicare Part B
This plan covers medical services deemed necessary by licensed healthcare professionals, along with:
- Home health care
- Ambulance fees
- Preventive services
- Therapy programs
- Certain prescription drugs
- Some eye care services
Medicare Part C
This plan is also known as the Medicare Advantage Plan, a combination of Part A and Part B, though with different restrictions and rules that affect how you receive care.
Medicare Part D
This plan is also known as the “Prescription Drug Benefit,” covering most outpatient prescription medication. This is often offered privately as a standalone plan or in combination with Plan C.
Does Medicare Cover Eye Exams?
Medicare Part B covers eye exams, but this coverage is quite specific. Generally, routine eye exams for vision correction aren’t covered. However, there are some exceptions. Medicare will cover eye exams if a person is previously diagnosed with:
- Diabetic retinopathy
- Glaucoma
- Age-related macular degeneration
To qualify for routine eye exam coverage, you need to apply for alternate coverage through other plans. Often, those who qualify for Medicare are also eligible for the STAR*PLUS plan listed above, which can help make eye care services much more acceptable.
Where to Book Your Next Eye Exam
Eye exams are something that should always be prioritized. They’re an essential part of taking care of your vision and making sure you’re not at risk of potential problems.
At TSO McAllen, we believe that eye care should be accessible. Ask us directly if you want to determine your eligibility for Medicaid or Medicare coverage.
Whether or not you’re covered by these insurance plans, our team will work closely with you to get you the eye care you deserve. Schedule your next appointment with our team today, and let’s work together to preserve your eye health and vision.
