Comparing Medicaid and Medicare payment rates for vitreoretinal surgeries | ASRS 2026

One of the many factors affecting access to healthcare for people covered by Medicaid is Medicaid’s relatively low reimbursement rates. The low rates can translate into a choice of far fewer providers because others don’t accept the lower Medicaid payment.

But data presented today at the 2026 annual meeting of the American Society of Retina Specialists (ASRS) in Montreal painted a more complex picture, with Medicaid programs in some states paying considerably more than Medicare and other states paying considerably less. The results showed that that the Medicaid reimbursement was highest relative to Medicare in Nebraska (84% higher than the Medicare rate) and lowest in New Jersey (48% lower). Overall, the Medicaid programs paid 88% less than Medicare for vitreoretinal surgeries, which is higher than the 75% across all medical specialties.

Ella H. Leung, M.D., of Georgia Retina, who presented the Medicaid vs. Medicare data referenced cuts to Medicaid funding during the question-and-answer period after she and two other researchers made presentations during the first half of a early afternoon session devoted to equity, access and population outcomes in retinal cae

“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. At the end of the day we all just need to speak to our senators, our congressmen, to tell them, ‘Hey, healthcare is a priority and should be a priority above other budgetary concerns,’” Leung told the ASRS audience.

Leung’s Medicaid-to-Medicare comparison focused on the 10 most common procedural terminology (CPT) codes among the vitreoretinal procedures, a group that includes CPT codes for five different types of vitrectomy, repairs of detached retinas, and several other types of vitreoretinal surgery. Using physician fee schedules and a weighted average of the procedures, Leung set out to compare Medicaid payment to Medicare payment on a state-by-state basis; Medicaid rates are set at the state level. She also made comparisons by CPT code.

She found that 34 states, comprising 82% of the total U.S. Medicaid enrollees, had lower Medicaid than Medicare rates, and 18 of those states had Medicaid rates less than 80% of their Medicare rates. After New Jersey, states with the lowest Medicaid rates were Washington (54% of Medicare), Rhode Island (58%), Connecticut (63%), Michigan (64%) and Maine (69%). After Nebraska, the states with the highest Medicaid rates were Arkansas (65% higher than Medicare), New Mexico (52% higher), Nevada (41%) and Alaska (40%).

When she looked at the Medicaid-Medicare reimbursement difference by CPT code, she found the biggest difference between Medicaid and Medicare payment was for 67121, the code for removal of implanted material with the Medicaid programs paying, on average, 71% of what Medicare pays. The narrowest gap between Medicaid and Medicare was for 67309, the code for pars plana vitrectomy with endolaser panretinal photocoagulation.

Approximately 12 million people in the U.S. are “dual eligibles,” meaning they are covered by both Medicaid and Medicare. Leung noted that some states have “lesser of” policies that pay for procedures by whichever rate is lower, Medicaid or Medicare.

Leung did an exploratory analysis of some rates for services others than vitreoretinal surgeries that might paint a more complete picture. For example, California is in the middle of the pack as far as the vitreoretinal surgeries, paying 84% of Medicare. But when Leung looked at four CPT codes for ophthalmic evaluation — 92002, 92004, 92012 and 92014 — she found that the state paid approximately a third of the Medicare rate, whereas Texas paid approximately 80% and New Jersey, just over 70%.