Medicare, Medicaid, and Keratoconus

People who are legally blind may qualify for Medicare under age 65 if receiving Social Security Disability Insurance (SSDI) benefits. This is especially important to realize if you are unable to work due to legal blindness for at least 12 months. Under SSDI rules, legal blindness is determined by revealing no more than 20/200 vision in your better eye on an eye test (e.g., Snellen Eye Chart) despite wearing corrective lenses.

Keratoconus can lead to legal blindness in a small percentage of affected adults (generally leading to significant financial stress if unable to work). Meanwhile, federal law requires Medicaid coverage for individuals receiving SSDI who are determined to have limited financial assets (based on state income guidelines).

The following describes the two major parts of traditional Medicare applicable to legally blind adults with keratoconus. If you have been diagnosed with keratoconus, the Precision Keratoconus Center may be able to assist you to choose the best course of action to preserve your vision.

Work Credits and Receipt of SSDI

 In order to qualify for SSDI as someone who is legally blind and under age 65, a work credit calculation is made by the Centers for Medicare and Medicaid Services (CMS); this is based on the dollar amount of earnings in a job (or self-employment) in which you paid Social Security taxes (along with the total number of years worked). According to the website of, a person between 31-42 years of age would need 20 work credits and five years of prior work to qualify for SSDI. There is also a five-month “waiting period” before SSDI payments can be made to any applicant approved to receive SSDI

A person who qualifies for SSDI is automatically enrolled in Medicare (Parts A and B) after 24 months of SSDI eligibility. However, expedited coverage is possible in some cases (e.g., a diagnosis of End-Stage Renal Disease [ESRD]).

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What is the Difference Between Medicare Part A and Part B?

Medicare Part A covers hospitalization (and at 80 percent of the total cost). Meanwhile, Medicare Part B covers healthcare provided outside of a hospital, such as outpatient physician visits. Diagnosis and treatment of specific eye disorders are covered under Medicare, and a corneal transplant (which is one of the surgical treatment options for severe keratoconus) is covered under Medicare.

However – according to the American Academy of Ophthalmology (AAO) – corneal cross-linking is only covered if an FDA-approved method (with concomitant approved medication) is utilized. Both Medicare Parts A and B only cover 80 percent of healthcare costs.

What is Medicare Supplemental Insurance or Medigap?

Medicare supplemental insurance (Medigap) is private insurance that can cover the remaining 20 percent of healthcare costs not covered by Parts A or B of Medicare. Some Medigap plans also include vision coverage (for routine exams and eyewear) which is not typically covered by Medicare. For anyone who has keratoconus and is legally-blind (and is not Medicaid-eligible), purchasing this extra coverage is a good idea.

The out-of-pocket costs for a corneal transplant are tremendous, so enrolling in a Medigap plan prior to undergoing a corneal transplant can significantly reduce your out-of-pocket costs. (You may also need to purchase a Part D drug plan to cover outpatient medications.)

Why a Corneal Transplant Can Be Needed

A corneal transplant in a keratoconus-afflicted person is typically recommended as a last resort when the cornea abnormality is causing persistent eye pain, and/or to restore vision when no other intervention has improved eyesight.  According to the National Keratoconus Foundation (NKF), 15-20 percent of people living with keratoconus ultimately require a corneal transplant.

A donor cornea will be needed in order to undergo corneal transplantation. Meanwhile, the “tissue match” of that cornea must be correct so the transplanted cornea will not be rejected by your body (requiring removal of the donated cornea). Moreover, the surgical technique termed Deep Anterior Lamellar Keratoplasty (DALK) is recommended to minimize the risk of organ rejection (according to the Cornea Research Foundation of America).

Your career does not need to end if you are legally blind and have keratoconus. A goal of the Precision Keratoconus Center is to improve your vision so that you can return to your normal professional and “at home” activities.

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