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Medicaid Coverage

Medicaid is the U.S. health program that provides medical benefits to groups of low-income people who may have no medical insurance or inadequate medical insurance.

Although the federal government establishes general guidelines for the program, each state sets Medicaid requirements and benefits — including Medicaid vision benefits. Whether or not you are eligible for Medicaid benefits depends on the guidelines your state adopts.

Federal Poverty Guidelines for Medicaid Eligibility

Income requirements to be eligible for Medicaid benefits vary from state to state, but generally are based on the federal poverty guidelines issued each year by the Department of Health and Human Services (HHS).

In 2009, the annual income levels constituting federal poverty level for families residing in the 48 contiguous states and the District of Columbia are:

• $10,830 for a single person
• $14,570 for a married couple
• $18,310 for a family of three
• $22,050 for a family of four
• For families with more than four persons, add $3,740 for each additional person

Federal poverty guidelines are 15 percent higher for U.S. citizens residing in Hawaii and 25 percent higher for residents of Alaska.

However, low income alone does not necessarily qualify a person for Medicaid benefits, and many poor Americans are not covered by the program. To be covered by Medicaid, you also meet other eligibility requirements established by the program as well. You can learn more about these criteria by contacting your state's Medicaid office.

Medical Benefits Available Under Medicaid

Medicaid eligibility groups classified as "categorically needy" are entitled to these and other health services, including treatment of eye diseases and other vision benefits:

• In-hospital stays, except in institutions for mental disease
• Out-patient hospital care in certain health clinics
• Laboratory services and x-rays
• Physicians' services
• Medical and surgical services of a dentist
• Early and periodic screening, diagnosis, and treatment (EPSDT) for children under 21
• Certain home health services
• Care during and after pregnancy

Medicaid pays the cost of these services directly to health care providers and not to Medicaid recipients. A person eligible for Medicaid benefits may be asked to pay a portion of the medical bill (the "co-payment") at the time a medical service is received.

In November 2008, a new federal rule gave states authority to charge premiums for Medicaid coverage and to force Medicaid recipients to pay higher co-payments for medical services as a means to reduce program costs. The rule, which is designed to carry out a law signed by President George W. Bush in February 2006, has been criticized by the American Academy of Pediatrics, AARP and other advocacy groups, who say the rule will make it more difficult for low-income children and older Americans to get needed medical care.

Medicaid Vision Benefits

The following vision benefits are available for children under 21 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program of Medicaid:

• Eye exams
• Eyeglass frames
• Lenses

Each state individually determines how frequently these services are provided.

Many states also offer similar vision services for adults. Some states also provide for glaucoma screening to help detect this common eye disease that can damage the eye's optic nerve and cause permanent vision loss.

Because cataracts clouding the eye's natural lens are a medical condition, Medicaid will also cover a portion of the cost of cataract surgery.

To learn more about Medicaid eligibility requirements and Medicaid vision benefits, call your state's Medicaid agency or visit the Department of Health and Human Services' website.

Resources:

Medicaid At-a-Glance 2005: A Medicaid Information Source. U.S. Department of Health and Human Services.

"New medicaid rules allow states to set premiums and higher co-payments." The New York Times. nytimes.com. November 2008.

[Page updated November 2009]