Medicaid’s lower reimbursement rates have long been cited as a barrier to care for patients who rely on the program, but new data presented at the American Society of Retina Specialists’ 2026 annual meeting in Montreal shows the picture varies widely across states.
State‑by‑state gaps between Medicaid and Medicare payments
Researchers examined the ten most common CPT codes for vitreoretinal procedures, which include several types of vitrectomy and retinal detachment repairs. By comparing physician fee schedules, they calculated a weighted average of Medicaid versus Medicare payments for each state.
The analysis revealed that 34 states—accounting for 82 % of Medicaid enrollees—pay less under Medicaid than Medicare. Eighteen of those states reimburse at less than 80 % of the Medicare rate. New Jersey had the lowest relative payment, at 48 % of Medicare, while Nebraska topped the list with Medicaid rates 84 % higher than Medicare.
Other states with low Medicaid rates included Washington (54 % of Medicare), Rhode Island (58 %), Connecticut (63 %), Michigan (64 %) and Maine (69 %). On the higher end, Arkansas pays 65 % more than Medicare, New Mexico 52 % more, Nevada 41 % more and Alaska 40 % more.
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Overall, Medicaid reimbursed 88 % less than Medicare for vitreoretinal surgeries, a gap larger than the 75 % disparity seen across all medical specialties.
Variation by procedure and the impact on patients
When the data were broken down by CPT code, the biggest gap appeared for code 67121, which covers removal of implanted material; Medicaid paid, on average, 71 % of the Medicare amount. The narrowest gap was for code 67309, a pars plana vitrectomy with endolaser panretinal photocoagulation.
About 12 million Americans are “dual eligibles,” meaning they receive both Medicaid and Medicare. Some states apply a “lesser‑of” rule, using whichever rate is lower for a given procedure, which can further reduce payments for these patients.
Dr. Ella H. Leung, of Georgia Retina, highlighted the practical implications during the session on equity and access. “I think a lot of the framework for how we present the data [should be] to emphasize that it is for our patients. All these cuts are going to ultimately affect patient access to care,” she told the audience. She urged clinicians to lobby legislators, noting that “healthcare is a priority and should be a priority above other budgetary concerns.”
Leung also looked beyond vitreoretinal surgery. In California, Medicaid reimbursed a similar proportion to Medicare for those procedures, yet for routine ophthalmic exams—CPT codes 92002, 92004, 92012 and 92014—the state paid roughly one‑third of the Medicare rate. By contrast, Texas covered about 80 % of the Medicare amount, and New Jersey paid just over 70 %.
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These discrepancies suggest that even within a single state, payment levels can differ dramatically depending on the type of service rendered.
Access varies widely.
Given the patchwork of reimbursement rates, it is plausible that states with lower Medicaid payments may see fewer retina specialists willing to accept Medicaid patients, potentially lengthening wait times and limiting access to timely care. If the trend continues, patients in those regions could face higher out‑of‑pocket costs or be forced to travel farther for treatment, outcomes that could strain an already stretched safety net.
Medicaid’s role in covering essential eye care remains important, especially for low‑income populations who might otherwise forgo treatment. The data presented at the ASRS meeting highlight the need for policymakers to consider how reimbursement structures affect provider participation and patient outcomes.
