Gaps in Medicaid Vision Care Coverage Leave Millions Without Essential Services

New research has revealed significant gaps in Medicaid coverage for vision care across the US, leaving millions of adults with low incomes without access to essential eye services.

Although most Medicaid enrollees have coverage for routine eye exams, approximately 6.5 million adults live in states without comprehensive exam coverage, and around 14.6 million lack access to glasses through Medicaid. Published in Health Affairs, these findings highlight the urgent need for policy changes, as vision impairment affects over 12 million Americans aged 40 and older—a number expected to double by 2050.¹

The study was led by Brandy Lipton, PhD, associate professor of health, society, and behavior at the UC Irvine Joe C. Wen School of Population & Public Health, and was based on state-by-state Medicaid data from 2022. The study demonstrated that while routine eye exams are often covered, many states do not cover corrective measures like glasses, with 20 states excluding glasses and 35 states not covering low-vision aids. These numbers echo those of recent Kaiser Family Foundation data reporting that 25% of US adults have unmet needs for routine vision care due to costs.² This inconsistency leaves many enrollees unable to afford the care they need.

“The positive finding from our study is that most fee-for-service Medicaid programs across the states covered routine eye exams, which are vital for detecting and addressing vision issues early,” said Lipton in a news release.³ “However, the substantial gaps highlight opportunities for policy changes to enhance coverage and access. Providing comprehensive vision care could have big benefits in terms of health, quality of life, and even employment and productivity”

Cost-sharing requirements also present barriers, deterring individuals with low incomes from seeking eye care. Managed care plans generally offer better coverage, but discrepancies between plans within states still lead to uneven access to services.

State-by-state coverage for routine eye exams and glasses under fee-for-service Medicaid varies significantly across the US | Image credit: NDABCREATIVITY – stock.adobe.com

State-by-state coverage for routine eye exams and glasses under fee-for-service Medicaid varied significantly across the US in 2022. Eight states provided coverage for both exams and glasses at least annually, 18 states covered them biannually, and 3 states covered them less frequently than every 2 years.¹ These states represent approximately 1.9 million, 12.2 million, and 0.9 million adult Medicaid enrollees, respectively. Additionally, 8 states covered only eye exams while 12 offered no coverage for either service, affecting about 2.6 million and 2.5 million enrollees, respectively. Notably, Washington, DC, covered glasses but not eye exams, impacting around 67,000 adult enrollees.

Of note, some states allow for additional exams and glasses when medically necessary, particularly for high-risk populations such as adults with diabetes. Maine has the most restrictive policy, offering glasses coverage only once per lifetime and only for extremely high corrections (a minimum of 10.0 diopters).

Regarding fee-for-service Medicaid coverage for routine eye care, 19 states allowed for the replacement of lost or broken glasses, covering approximately 10.6 million enrollees. Meanwhile, 15 states provided low vision aids for enrollees whose vision issues cannot be corrected with standard prescription lenses, affecting around 9.6 million enrollees, and 14 states covered eye exams or glasses with no out-of-pocket costs for enrollees, benefiting about 7.3 million individuals. Additionally, 10 states covered glasses without requiring a specific minimum diopter correction, impacting 2.8 million enrollees.

Managed care coverage tended to be more generous but was not always complete in the states lacking fee-for-service coverage for eye exams and glasses. Among the 13 states without fee-for-service eye exam coverage, 4 of them offered full coverage through both managed care plans, 1 provided full coverage through a single managed care plan, and 5 offered no managed care coverage for exams. The remaining 3 states lacked a comprehensive managed care plan.

Meanwhile, in the 20 states without fee-for-service coverage for glasses, 3 had full coverage through both managed care plans, another 3 had full coverage through a single plan, 3 offered partial coverage, and 7 provided no glasses coverage. The remaining 4 states either lacked a comprehensive managed care plan or excluded glasses from coverage.

The study authors listed a number of limitations, notably that fee-for-service provider manuals for 11 states were dated prior to 2018, including Hawaii, where it was determined that all enrollees were covered through managed care. For the other 10 states, updated information was obtained by directly contacting 9 state Medicaid agencies, with no response from New Hampshire.

The aging population in the US is a major reason that the number of adults with vision impairment is projected to double in the next 25 years. According to the authors, expanding access to routine vision care could enhance the diagnosis and treatment of uncorrected refractive errors, which are a leading cause of vision impairment.

“Routine vision care may also facilitate the early detection of eye diseases that can lead to vision loss,” they added. “Although examining the impacts of state-level Medicaid policies on rates of difficulty seeing was outside the scope of this analysis, previous research supports the notion that providing vision benefits can increase eye care access and reduce vision problems.”

References

1. Lipton BJ, Garcia J, Boudreaux MH, Azatyan P, McInerney MP. Most state Medicaid programs cover routine eye exams for adults, but coverage of other routine vision services varies. Health Aff (Millwood). 2024;43(8):1073-1081. doi:10.1377/hlthaff.2023.00873

2. Lopes L, Montero A, Presiado M, Hamel L. Americans’ challenges with health care costs. KFF. March 1, 2024. Accessed August 13, 2024. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/

3. UC Irvine-led study finds inconsistent state-by-state vision care coverage. News release. UC Irvine. August 7, 2024. Accessed August 13, 2024. https://publichealth.uci.edu/2024/08/07/uc-irvine-led-study-finds-inconsistent-state-by-state-vision-care-coverage/