Does West Virginia Medicaid Cover Vision?

By - September 14, 2021

Does West Virginia Medicaid Cover Vision? In West Virginia, 29 percent of the population is covered by Medicaid services. This means that over 560,000 people rely on Medicaid for their health care coverage in this state. 

Eligibility for Medicaid depends on the income and number of people in a household. For example, in West Virginia, a single person making no more than $16,612.00 per year qualifies for coverage. Also, a family of eight with an annual income of no more than $57,762.00 qualifies. 

People who don’t meet the required income criteria can still qualify for Medicaid if they spend enough on healthcare services to meet the income levels. This is known as the spend-down program, and it especially benefits the elderly, blind, and disabled.

If you don’t meet the financial requirements mentioned above, you may still be qualified as a dual-eligible beneficiary. This means that you can get health care coverage from your Medicare benefits and from Medicaid services together.

Those who are over 65, or have ALS, or have end-stage renal disease, or have been getting Social Security Disability Income benefits for 25 months may qualify for dual eligibility. Dual-eligible beneficiaries typically have access to a special enrollment period when they can enroll in a D-SNP (dual-eligible special needs plan) anytime during the year. 

How does Medicaid in West Virginia cover vision care?

Adults who have Medicaid coverage alone in the state have the following limited vision care allowances:

  • Eye exams that are certified as medically necessary.
  • One pair of eyeglasses and frames (with limited warranty) for beneficiaries who have had a cataract removed within the past 60 days. 
  • Contact lenses for people who have been diagnosed with either Keratoconus or Aphakia.
  • Artificial eye prosthesis with certification of medical necessity

How do D-SNPs cover vision care in West Virginia?

Dual-eligible Special Needs Plans (D-SNPs) are special Medicare Advantage plans that include benefits for individuals with Medicare and Medicaid. They will include Part A and Part B coverage along with additional benefits such as dental, vision, and hearing care. These plans are available to people who meet low-income or health-condition requirements and have little, or no, monthly costs for beneficiaries. 

Because D-SNPs are sold by private insurance companies, additional benefits vary from plan to plan. 

Generally, the vision care services that are covered by a D-SNP in West Virginia are: 

  • Routine eye exams: Some plans offer one exam per year and others offer two routine vision eye exams every year.
  • $0 copay for routine eye exams: Available from most DSNP providers.
  • Specialist eye exam: Available with some plans and with referral from a primary care physician.
  • Yearly allowance for eyewear and contact lenses: Generally between $100.00 and $400.00 depending on your plan. Eyewear allowances can be used for in-house frames, lenses, lens extras, contact lenses.
  • Eyewear after cataract surgery: Most plans offer coverage for one pair of glasses with standard frames and lenses or one pair of contact lenses. These are not deducted from the yearly allowance for eyewear.
  • Glaucoma screening: Most plans provide coverage for one screening exam per year for beneficiaries considered to be at higher risk for glaucoma. These can include people with a family history of glaucoma, those with diabetes, African-Americans 50 and over, and Hispanic-Amer

If you live in West Virginia and qualify for Medicaid alone, or as a beneficiary who is eligible for both Medicare and Medicaid coverage, you may have access to routine vision care services. 

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