Medicaid covers cataract surgery in all states, but the details of what it pays for and how you access it depend on which Medicaid program you're in
Medicaid will cover the cost of cataract surgery itself — the procedure to remove the clouded lens and usually replace it with an artificial one. However, Medicaid does not cover all the expenses that come with it. The program pays for the surgery and the basic intraocular lens (IOL), but you may have to pay out of pocket for premium lens options, pre-surgery testing, or post-surgery glasses and contact lenses. Coverage also varies depending on whether you're in traditional Medicaid, a Medicaid managed care plan, or a state-specific program.
The first step is to confirm you're still covered under Medicaid — many people lost coverage during the pandemic and have not re-enrolled. Then you'll need to find an ophthalmologist or eye surgeon who accepts your specific Medicaid plan. Not all eye doctors take Medicaid, and not all Medicaid plans cover the same providers.
Key Takeaways
- Medicaid covers the surgical procedure and a standard intraocular lens, but premium lens upgrades and vision correction after surgery are usually your responsibility.
- You must see an ophthalmologist or eye surgeon who is in-network with your specific Medicaid plan; calling the plan directly is the fastest way to find one.
- Your Medicaid plan may require a referral from your primary care doctor or pre-authorization from the plan before you schedule surgery.
- If you need cataract surgery but are not currently enrolled in Medicaid, you can re-enroll through your state's Medicaid office or healthcare.gov.
What Medicaid pays for and what you pay
Medicaid covers the surgical procedure itself, which includes the surgeon's fee, the operating room, anesthesia, and the basic monofocal intraocular lens (IOL) — a standard single-focus artificial lens. This is the lens that most Medicaid programs consider medically necessary.
You will likely have to pay out of pocket for premium lens options. These include multifocal lenses (which correct vision at multiple distances), toric lenses (which correct astigmatism), and other specialized lenses. The cost of upgrading to a premium lens varies by surgeon and state, but typically ranges from several hundred to several thousand dollars per eye. Ask your surgeon for the exact price before you commit.
Medicaid also does not cover the cost of glasses or contact lenses you may need after surgery, even if your vision is not perfect after the procedure. You can purchase these through a separate vision plan, a discount retailer, or out of pocket. Some states offer separate vision benefits for Medicaid members, so check with your plan.
How to find a doctor who accepts your Medicaid plan
Not every eye doctor accepts Medicaid, and not every Medicaid plan covers the same doctors. The fastest way to find an in-network ophthalmologist is to call your Medicaid plan directly. The phone number is on your Medicaid card or on your state's Medicaid website.
When you call, tell them you need an ophthalmologist or eye surgeon who performs cataract surgery. Ask whether you need a referral from your primary care doctor first, and whether the plan requires pre-authorization before you schedule. Some plans let you call the eye doctor directly; others require the referral or authorization to come from your primary care doctor.
If you do not have a primary care doctor, ask your Medicaid plan how to find one, or ask the eye doctor's office whether they can help you get a referral. Many eye doctors' offices are used to working with Medicaid and can guide you through the process.
Referrals and pre-authorization requirements
Many Medicaid plans require a referral from your primary care doctor before you can see a specialist like an ophthalmologist. Some plans also require pre-authorization — meaning the plan must approve the surgery before it happens. Requirements vary by state and by plan type.
If your plan requires pre-authorization, the eye doctor's office usually handles submitting the request to Medicaid. They will send documentation showing that you have a cataract that is affecting your vision and that surgery is medically necessary. Medicaid typically approves these requests within one to two weeks, though it can take longer if the plan needs more information.
Do not schedule surgery until you have confirmation from Medicaid that it is pre-authorized. If you have surgery without pre-authorization and your plan denies it, you could be responsible for the full cost.
Differences between traditional Medicaid and managed care plans
Traditional Medicaid is run directly by your state. Medicaid managed care plans are run by private insurance companies that contract with your state. Both cover cataract surgery, but the process and the doctors available to you may differ.
In traditional Medicaid, you usually have more freedom to choose which eye doctor you see, as long as they accept Medicaid. In a managed care plan, you must see an in-network doctor or you may have to pay more out of pocket. Managed care plans also more often require referrals and pre-authorization.
To find out which type of Medicaid you have, look at your Medicaid card or call your state's Medicaid office. The name of your plan will be on the card if you're in a managed care plan.
What to do if you are not currently enrolled in Medicaid
If you lost Medicaid coverage or have never enrolled, you can re-enroll through your state's Medicaid office or through healthcare.gov. Medicaid is available year-round, unlike private health insurance, so you can enroll at any time if you meet your state's income and other requirements.
Income limits vary by state and by family size. Most states cover adults with income at or below 138% of the federal poverty level, though some states have lower limits. You can check your state's specific income limit on your state Medicaid website or by calling your state's Medicaid office.
The enrollment process usually takes one to two weeks. Once you are enrolled, you can contact your plan to find an eye doctor and begin the process of scheduling cataract surgery.
What happens after surgery
Medicaid covers post-surgery follow-up visits with your eye surgeon to make sure your eye is healing correctly. These visits are usually scheduled at one day, one week, and four weeks after surgery, though the exact schedule depends on your surgeon.
If you experience complications after surgery — such as infection, inflammation, or vision problems — Medicaid will cover treatment for those complications. However, if you choose a premium lens and have problems with it, you may have limited recourse through Medicaid since the plan only covers the standard lens.
Frequently Asked Questions
Do I need to pay anything out of pocket for cataract surgery under Medicaid?
You should not have to pay anything for the surgery itself or the standard lens if you see an in-network doctor and the surgery is pre-authorized. However, if you choose a premium lens upgrade, you will pay that cost out of pocket. Some people also pay for glasses or contacts after surgery if their vision is not perfect.
What if my eye doctor is not in my Medicaid plan's network?
Call your Medicaid plan and ask whether they will cover an out-of-network doctor. Some plans will pay a portion of the cost if you get permission in advance, but you may have to pay more than you would with an in-network doctor. It is usually cheaper to find an in-network eye surgeon.
How long does it take to get cataract surgery approved by Medicaid?
If your plan requires pre-authorization, approval usually takes one to two weeks. The eye doctor's office submits the request, and Medicaid reviews it to confirm the surgery is medically necessary. If Medicaid needs more information, it can take longer.
Can I get a premium lens and have Medicaid pay part of it?
No. Medicaid covers only the cost of a standard monofocal lens. If you want a premium lens, you pay the full upgrade cost yourself. Some surgeons offer payment plans to spread the cost over time.
What if I have both Medicaid and Medicare?
If you have both, Medicare is usually your primary insurance and Medicaid is secondary. Medicare covers cataract surgery for people 65 and older and some younger people with disabilities. Contact Medicare first to understand what it covers, then contact Medicaid to see whether it will cover any remaining costs.