Access and Coverage

Why it matters

Vision and eye care must be affordable and accessible to prevent avoidable blindness and protect quality of life.

This page is about our policy and advocacy work. If you need help navigating your own eye care benefits, visit Understanding Insurance Benefits for Eye Care on the main Prevent Blindness site.

Most people use public or private insurance to address their vision and eye care needs. Yet core public insurance programs, such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and insurance plans under the Affordable Care Act (ACA), often exclude vision or provide it as an optional benefit with high cost-sharing, leaving millions without routine exams, eyeglasses, low vision devices, or needed treatments. Private insurance plans, such as those offered through an employer, typically cover only a fraction of the cost of eyeglasses, contact lenses, and eye exams. Employer-sponsored medical insurance plans may cover eye care services but may also feature high out-of-pocket costs before someone can access it.

Often, cost is the barrier for individuals.

Access and affordability are relative terms: if someone cannot afford eye care, they cannot access it. Likewise, if a person can afford eye care but lives far from a practicing eye care provider, they cannot access it. According to the (CDC), in 2017, 4 in 10 adults in the United States are considered to be at high risk of vision loss; and yet, 40% of those at highest risk did not receive an eye exam within the past year. In addition, 8 million adults who know they need eyeglasses could not afford them.

What we're working toward

  • Strengthen Medicare coverage for routine eye exams, eyeglasses and contact lenses, and low vision devices
  • Protect and improve rates of pediatric vision benefits provided under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit under Medicaid and CHIP
  • Safeguard pediatric vision care as an essential health benefit under the ACA, and push for adult vision coverage, including screenings for serious conditions like glaucoma, diabetic retinopathy, and others
  • Ensure digital detection pathways (such as telehealth and AI) improve access to eye care rather than replacing in-person exams
  • Improve utilization management practices used by insurers such as prior authorization or step therapy so patients do not experience delays in timely treatment or disruption to the patient-provider relationship in decision-making.
  • Incorporate the patient’s experience in policies that reform drug pricing, such as the Medicare Drug Price Negotiation Program and others.

Medicare

Nearly 60 million older Americans rely on Medicare, yet its coverage of vision and eye health services is generally limited to medical need and high risk. While some Medicare Advantage plans offer vision benefits, such as eyeglasses and contact lenses, those plans may not be the best option for seniors based on other health conditions they may face. Without access and coverage for vision and eye care services, older adults may unnecessarily face suboptimal health outcomes and higher long-term costs. Step therapy in Medicare Advantage on certain Part B drugs can also delay sight-saving treatment by requiring that patients try less-effective, cheaper drugs before they can be treated with the drug prescribed by their physician.

Our Priorities

  • Create a Medicare coverage pathway for low vision devices and assistive technology
  • Address step therapy on certain Part B drugs in Medicare Advantage, which can delay the treatment a patient’s physician prescribed
  • Integrate vision into Medicare’s preventive and aging-related care

Advocacy in Action

  • Joined Independence Through the Enhancement of Medicare and Medicaid (ITEM) Coalition comments urging CMS to preserve coverage of medical devices and assistive technologies under essential health benefits.
  • Submitted comments opposing step therapy under Medicare Advantage

Medicaid & Children’s Health Insurance Program (CHIP)

Medicaid and CHIP provide health care to millions of low-income children and families. Under existing law, as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, pediatric vision services are available to children under 21 who are enrolled in Medicaid or CHIP. Adult coverage for vision and eye care varies widely by state and is often considered an optional or supplemental benefit.

Our Priorities

  • Strengthen EPSDT reporting so vision screenings and referrals are completed, not just offered
  • Support the ongoing authorization of CHIP so children’s coverage doesn’t lapse
  • Encourage states to integrate vision into chronic disease and public health programs

Advocacy in Action

Affordable Care Act (ACA)

The ACA requires insurance plans to cover services deemed “essential health benefits” (EHBs). In general, pediatric vision care is considered an EHB (though the actual covered services depend on state requirements for plans). While preventive and wellness services for chronic disease management is covered as an EHB, adult vision coverage is not considered an EHB, which leaves millions of adults without affordable coverage for vision and eye health services.

Our Priorities

  • Protect pediatric vision care as an essential health benefit
  • Support recognizing adult vision screenings and assistive devices as essential health benefits
  • Protect the affordability of ACA coverage so people don’t lose access

Advocacy in Action

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Looking for help with your own coverage?

This page is about our policy and advocacy work. If you need help navigating your own eye care benefits, visit Understanding Insurance Benefits for Eye Care on the main Prevent Blindness site.