Are you in need of cataract surgery but wonder if Medicaid covers such a procedure?
We’re here to help. In this article, we’ve discussed the use of Medicaid for vision care. As you read further, you’ll learn about the services covered and whether you must pay for cataract surgery.
Medicaid Cataract Surgery
Are there other services covered by Medicaid? Hang around for details! By the end, you should know what it takes to get cataract surgery under the Medicaid program.
With such information, you can take advantage of available opportunities.
A basic definition of cataract is a visual condition that causes the clouding of the eye’s lens, which is supposed to be precise. For persons affected by this condition, it will feel like they’re looking through a cloudy or frosty lens.
This blurry condition is due to blockage of the clear part of the eye that focuses light. Due to advancements in medical care, surgical interventions can rectify the problem.
Medicaid surgeries are of different kinds, the most common being extracapsular cataract extraction (ECE).
Other cataract surgeries include femtosecond laser-assisted surgery and phacoemulsification, also called phaco for short. This is the focus of discussion as we intend to answer the question: does Medicaid cover cataract surgery?
Actual Cost of Cataract Surgery
To appreciate the coverage provided by programs like Medicaid, you need to understand or know the costs involved during surgery.
MyVision.org, a non-profit with a panel of experts, offers valuable information on treatment costs for vision care procedures like cataract surgery.
According to the information, the average cost for cataract surgery is around $3,500 per eye.
However, certain conditions can impact expenses of as much as $7,000 per eye. With this reality, it’s clear that paying out-of-pocket for cataract surgery can be pretty expensive.
As a low-income earner, the logical option will be to seek some form of subsidy. Luckily, many programs are aimed at subsidizing vision care, including complex procedures like cataract surgery.
Does Medicaid Pay for Cataract Surgery?
Our discussion to this point has been aimed at better highlighting the scope of Medicaid, especially as it concerns cataract surgery. So, does Medicaid pay for cataract surgery? Medicaid does pay for cataract surgery as it’s considered a medically-essential procedure.
However, certain factors might affect Medicaid payment or coverage for cataract surgery. Examples of these include co-payments & deductibles.
Others have a medical necessity, prior authorization, state-specific policies, visual acuity & age criteria, and a provider network.
What Aspects of Vision Care Does Medicaid Cover?
One of the main discussions that need to be had on this topic is the extent of Medicaid. It’s no secret that Medicaid includes vision care.
However, what services are included? Medicaid pays for services like contact lenses, screenings for glaucoma, eye exams, eyeglass frames, and prescription eyeglass lenses.
Medicaid may also cover services like providing visual aids & assistive devices, pre & post-operative care, and vision therapy.
Additional benefits under Medicaid include eye surgery, optometric services, and vision screening for children. We must also state that this isn’t an exhaustive list of vision care procedures covered by Medicaid.
It’s also important to mention that Medicaid coverage for the vision care services mentioned isn’t the same across all states.
In other words, each may be covered to a certain degree depending on the state’s Medicaid program design, state budgetary constraints, priorities, etc.
What Cataract Surgery Costs Come Down to with Medicaid
We mentioned earlier that paying out-of-pocket for cataract surgery can be pretty prohibitive, with average costs around $3,500 to $7,000.
While that is true, Medicaid significantly subsidizes these costs. When you have to pay around $977 for surgery in a clinic, Medicaid slashes the price to about $195.
When visiting hospitals for cataract surgery, the average cost might be around $1,917. With Medicare coverage, you might end up paying only about $383.
This is why you need Medicaid to pay for a significant part of your surgery costs.
More Factors that Affect Medicare Cataract Surgery Costs
Several factors were given earlier for surgery cost disparity as it involves Medicaid.
More factors that might affect the cost of cataract surgery under Medicaid include the type of surgery needed, potential complications, where the surgery is had, surgery duration, and medical conditions you might have.
Your Medicaid plan is another crucial factor in determining how much you pay. Let’s briefly discuss some of these points for more clarity.
i. Type of Surgery Required
The required type of cataract surgery under Medicaid will determine the coverage’s extent.
There are standard cataract surgery procedures and more complex or advanced surgeries. Due to the complex nature of such surgeries, the scope may be limited under Medicaid.
ii. Potential Complications
When it comes to surgical procedures, there’s never a 100% certainty that it will go as planned. In other words, complications might arise. This could lead to extended post-operative care and revision of secondary procedures.
Based on this reality, Medicaid coverage is assessed on a case-by-case basis.
iii. Where the Surgery is Had
Not all facilities (whether clinics or hospitals) will be considered in-network.
In other words, a facility may be enrolled under the Medicaid program or may not be. For out-of-network facilities, you wouldn’t expect Medicaid coverage for cataract surgery.
iv. Surgery Duration
The longer a cataract surgery procedure takes, the more likely it will be considered to be complex.
This directly impacts the charges for the operating room and anesthesia. Because Medicaid typically covers such costs, it might have some impact.
v. Medical Conditions
Before cataract surgery, Medicaid provisions might come with pre-conditions, such as the absence of pre-existing eye surgeries. The presence of other eye conditions could also affect Medicaid coverage for such surgery.
vi. Medicaid Plan
For the most part, Medicaid follows federal guidelines and state-specific policies.
This means coverage isn’t the same across all states. You’ll have to deal with coverage criteria, medical necessity, cost-sharing, and your state’s Medicaid policies.
Medicaid covers cataract surgery but to varying degrees, as discussed above. If you’re planning on having surgery or know someone who is, you might want to use the information in this guide to have a smooth process.