Study finds Medicaid vision coverage for adults varies widely by state

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The National Institutes of Health (NIH) supported a study that shows 6.5 million Medicaid enrollees (12%) live in states without coverage for routine adult eye exams; and 14.6 million (27%) reside in states without coverage for eyeglasses.

The study is based on 2022-2023 coverage policies, and was published in Health Affairs. It is among the first to provide a state-by-state analysis of adult Medicaid benefits for basic vision services in both fee-for-service and managed care.¹

According to an NIH news release, Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. The federal government sets up overall rules for Medicaid, but programs are run by each state. The states set their own rules that determine eligibility and coverage policies. The law allows states to set the coverage of eye exams and eyeglasses for adults.²

However, for children, federal law entitles Medicaid-enrolled infants, children, and adolescents to Medicaid coverable, appropriate, and medically necessary services needed to correct health conditions. This includes vision services.

“Our study clearly shows that there are opportunities to expand coverage of routine vision services at the state level, and based on previous research, we expect more generous coverage would reduce rates of vision impairment, improve quality of life, and promote health equity,” Brandy Lipton, PhD, study author and associate professor of health, society and behavior at the University of California, Irvine, said in the news release.

For many visual conditions, an examination by an ophthalmologist or optometrist is the only way to diagnose eye diseases early, when treatment has the best chance to prevent permanent vision loss. Eye examinations also are key to getting a prescription for glasses to correct refractive error.

According to the NIH news release, an analysis of 2020 Medicaid enrollee data, and 2022-2023 coverage policies, found that state-level coverage for adults varied widely. The gaps in coverage included:

In 20 states, fee-for-service Medicaid policies did not cover glasses at all; and in 12 of those states, eye exams were also not covered.

Seven states had no coverage for exams or glasses under both fee-for-service and managed care policies (Arizona, Idaho, New Mexico, Oklahoma, Tennessee, West Virginia, and Wyoming).

Thirty-five states did not cover low vision aids such as magnifiers and loupes.

“Visual impairment can be corrected with glasses in most instances, but not all. Particularly among older adults, lack of coverage for low vision aids may be an important gap,” Lipton said in the news release.

Moreover, even in states that had coverage for vision care services, the copays and restrictive policies could prove to be a barrier for enrollees following through on an exam for glasses. The study found that two-thirds of states required enrollees to cost share.²

The NIH noted that Medical Expenditure Panel Survey data found that an uninsured adult seeking an eye examination would have to pay about $485 in out-of-pocket expenses, more than a third of the monthly income for a single adult living at or below the federal poverty level.

According to the study, Maine had the most restrictive glasses coverage policy, with glasses covered just once in a lifetime, and only for people who required an unusually strong prescription to correct their vision.²

The NIH also noted that separate research has found that vision impairment can increase the risk of falls and hip fractures, difficulties performing activities of daily living, social isolation, depression, cognitive impairment and mortality.

“Reducing disparities in vision care is a powerful way to improve quality of life for everyone,” NEI Director Michael F. Chiang said in the news release. “This study points to opportunities for expanding coverage to reduce inequities in basic vision care for people with lower incomes.

The NIH also noted in its news release that as the US population ages, it is expected that the number of people with vision impairment from all causes will double by 2050.

The study was funded by NEI grant R01EY033746.

References:

1. Lipton, BJ; Garcia, J; Boudreaux, MH; Axatyan, P; and McInerney, P. “Most state Medicaid programs cover routine eye exams for adults, but coverage of other routine vision services varies.” Published August 5, 2024, Health Affairs. DOI:10.1377/hlthaff.2023.00873

2. NIH-funded study finds lack of coverage, copays, restrictive policies barriers to vital eye care for adults. Nih.gov. Published 2024. Accessed August 13, 2024. https://www.nei.nih.gov/about/news-and-events/news/medicaid-vision-coverage-adults-varies-widely-state