Does Medicare Pay For Eye Exams?
Medicare does not cover routine eye exams unless you have diabetes, glaucoma or macular degeneration. Read our guide to find out what options you have as you look for coverage for eye coverage.
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Original Medicare (Medicare A and B) does not pay for routine eye exams, eyeglasses or contact lenses.
There may be special exceptions if you have diabetes, glaucoma, or macular degeneration.
A Medicare Advantage plan may offer additional coverage that could include routine eye exams, eye glasses or contact lenses.
Original Medicare (Medicare Part A and Part B) does not pay for routine eye exams, except in special circumstances. You will be responsible for the entire cost of those services out of pocket. There are ways, however, to get the vision health coverage you need. We'll tell you how to do it.
What is Covered Under Original Medicare?
Although Medicare doesn't cover routine eye care, it will pay for your eye exam to determine whether you have a serious eye condition. Even if it turns out that you're not diagnosed with an eye problem, the diagnostic visit is still covered.
Does Medicare Cover Eyeglasses or Contact Lenses?
Original Medicare does not cover eyeglasses or contact lenses. However, Medicare will pay for one set of eyeglasses or contact lenses post-surgery if you've had surgery for cataract removal.
Does Medicare Cover Eye Exams If You Have Diabetes?
If you have been diagnosed with diabetes, Medicare Part B will pay for an annual eye exam to check for diabetic retinopathy, a common complication of diabetes. This exam must be conducted by an eye doctor who has been approved to offer this exam in your state.
Medicare Part B will cover 80% of the cost, and you will be responsible for 20% unless you have other insurance such as a Medicare Supplement plan (also known as Medigap) to cover out-of-pocket costs. Medicare Part B also requires you to meet a yearly deductible; this also may be covered by Medigap.
Does Medicare Cover Eye Exams If You Have Glaucoma?
Medicare Part B covers a glaucoma test once a year if you are considered high-risk for developing glaucoma.
You are considered at high-risk for glaucoma if you:
Have a family history of glaucoma
Are African-American and over the age of 50
Are Hispanic and over the age of 65
Just like the coverage for diabetes, Medicare will pay 80% of the cost, and you will be responsible for 20% out-of-pocket.
Does Medicare Cover Eye Exams If You Have Macular Degeneration?
If you have age-related macular degeneration, Medicare Part B may pay for certain tests and treatments related to this condition.
Ask your doctor whether the specific test or service you need is covered by Medicare.
Does Medicare Cover Eye Exams If You Have Cataracts?
If you have cataracts, it is recommended that you see an eye doctor each year for a routine eye exam, but the cost of this exam is not covered by Original Medicare. You are responsible for the entire cost. However, if you choose a Medicare Advantage plan instead of Original Medicare, you may be able to receive routine vision coverage.
If you need cataract surgery, Medicare Part B covers cataract surgery as long as your doctor deems the surgery medically necessary and accepts Medicare plans.
How Can You Get Your Routine Eye Exams Paid For By Medicare?
If none of the special circumstances above apply to you, don't give up yet. It's still possible for you to obtain Medicare coverage that will pay for routine vision care.
A Medicare Advantage plan is an alternative way of getting your Medicare benefits. These are healthcare plans that are offered by Medicare-approved private companies, and they take the place of Medicare A and B if you choose to enroll in one of them.
Medicare Advantage plans offer a variety of additional benefits that are not covered under Original Medicare. Vision, dental, wellness and hearing services are offered in many of these plans.
Extra items such as adult daycare services, transportation to medical visits, and over-the-counter medications also may be included. Medicare Part D, which covers prescription medication, is also usually incorporated into these plans.
Unlike Original Medicare, which is accepted almost everywhere, Medical Advantage plans usually have a local network of preferred providers. Like many employer health plans, they may not cover services that are out of network, or they may cover a smaller portion of out-of-network services. They may also have certain rules for referrals and other services, so be sure you understand what is required of you under the plan.
If you choose a Medicare Advantage plan in place of Original Medicare, you have the choice each year to keep your current plan, change to another Medicare Advantage plan or go back to Original Medicare.
Routine eye exams are a crucial part of maintaining your vision health as you age. Although these services are not usually covered by Original Medicare, you can still obtain routine vision coverage through a Medicare Advantage plan.
Should You Enroll in a Medicare Supplement Plan?
Medicare Supplement plans are private insurance plans that help "fill in the gaps" of Medicare. They may pay for deductibles, copayments and other out-of-pocket costs that Original Medicare doesn't cover.
Each of the 10 standardized Medigap plans (A, B, C, D, F, G, K, L, M and N) can help in various ways to pay out-of-pocket costs of covered services. However, a Medigap plan doesn't change the items or services that are covered.
If you have opted to keep Original Medicare (instead of choosing a Medicare Advantage plan), and you don't meet the special requirements for routine vision coverage, you'll still be responsible for the costs of your own vision health.
For more information about which healthcare options cover you eye needs, consult with a licensed Medicare insurance agent. They can help you find the coverage you need to help you continue to see clearly for years to come.
Courtney Schmidt is a medical communications professional and clinical pharmacist with pediatric and adult hospital experience.