# May, 04, 2020

Does Medicare Cover Eye Exams? Vision Coverage for Seniors

America’s only national health insurance, Medicare, covers a wide range of healthcare services for seniors. But does Medicare cover eye exams and other routine vision care? The answer depends on whether you have or are considered high risk for certain medical conditions. In this post, we explain when Medicare covers routine vision care, screenings, and prescription lenses.

Does Original Medicare Cover Eye Exams?

Original Medicare consists of Part A, hospital insurance, and Part B, medical insurance. So, a better question might be, Does Medicare Part B cover eye exams? And the answer is, not usually.

Medicare Part B considers routine eye exams those you get to determine whether you need prescription glasses or contact lenses. Which likely leads to your next question: Does Medicare cover prescription glasses? And, again, the answer depends on whether you have or are considered high-risk for certain medical conditions. In both cases, these are:

  • Diabetes
  • Cataracts
  • Glaucoma

Medicare may also cover an eye exam if the goal is diagnosing the reason behind problems with your vision. Typically, this means age-related macular degeneration.

When Does Medicare Cover Eye Exams for Diabetics?

If you have diabetes, Medicare Part B covers one eye exam per year. This is because the goal is not to prescribe glasses but to determine whether you have diabetic retinopathy. This rare condition may occur in diabetics whose blood sugar is not under control.

There is no cure for diabetic retinopathy. However, the condition can be managed with diabetes care, particularly controlling blood sugar. Early symptoms of diabetic retinopathy include:

  • Blurred vision
  • Dark areas in your vision
  • Difficulty distinguishing colors
  • Floaters

If left untreated, diabetic retinopathy may cause blindness.

To ensure the service is covered, you must use a Medicare optometrist, meaning one who accepts assignment. In addition, your doctor must be approved by your state to perform the eye exam. Your cost is 20 percent of the Medicare-approved amount and the Part B deductible applies. If you undergo the exam as a hospital outpatient, you are responsible for a copayment. Talk to your provider to determine your full out-of-pocket cost.

When Does Medicare Cover Prescription Eyeglasses or Contacts?

Medicare covers prescription eyeglasses or contacts if you underwent intraocular lens placement associated with cataract surgery. Your cost is 20 percent of the Medicare-approved amount for a standard pair of untinted prescription lenses. This assumes you go to a provider who accepts assignment. Medicare will only pay for customized prescription lenses if they are deemed medically necessary.

For all other prescription eyeglasses and contacts, you are responsible for 100 percent of the cost.

When Does Medicare Cover Eye Exams for Glaucoma?

Medicare covers a yearly eye exam by a state-authorized, Medicare eye doctor if you are considered high risk for glaucoma. “High risk” includes beneficiaries who:

  • Have a family history of glaucoma
  • Have diabetes
  • Are African American and over age 50
  • Are Hispanic American and over age 65

Your cost for the glaucoma test is 80 percent of the Medicare-approved amount. If you receive the test as a hospital outpatient, you also have a copay. The Medicare Part B deductible applies. A state-approved doctor must either supervise or perform the screening.

Medicare Coverage for Macular Degeneration

If you complain of vision problems, your doctor may recommend a macular degeneration test. Unlike a routine eye exam, this usually involves viewing an Amsler grid, which consists of a central dot surrounded by straight lines. If the surrounding lines seem wavy or blurred while you stare at the dot, this may indicate macular degeneration. The most common treatment is anti-VEGF injections directly into the eye to promote the growth of healthy blood vessels.

Medicare covers these tests and treatment when deemed medically necessary. You pay 20 percent co-insurance and the Medicare Part B deductible applies.

Does Medicare Advantage Cover Eye Exams?

Over one-third of Medicare beneficiaries choose Medicare Advantage (MA) over Original Medicare. This is because most MA plans – over 80 percent – offer at least some level of additional coverage for all four of the following:

  • Routine dental care is covered by 88 percent of MA plans
  • Fitness benefits are offered by 93 percent of MA plans
  • Eye exams and glasses are covered by 87 percent of MA plans
  • Hearing aids are covered by 83 percent of MA plans

Original Medicare, of course, does not cover any of these benefits. If you’re looking for Medicare optometry coverage, your best bet is a Medicare Advantage plan.

Comparing Medicare Advantage Plans

At a minimum, every MA plan must offer the same level of coverage as Original Medicare. Most offer additional benefits, though. When comparing Advantage plans, look at both the benefits and the full cost of the plan.

  • Drug formulary: Most MA plans include prescription drug coverage. Before choosing the plan, check the formulary to be sure it includes your prescriptions.
  • Provider network: Most Advantage plans also have a provider network. Using a provider who isn’t in the plan’s network could leave you footing 100 percent of the bill. Either choose a plan whose network includes your providers or change to a doctor who participates in your plan’s network.
  • Extra benefits: Even if you have an MA plan, you’re still responsible for your monthly Part B premium. So, make sure the extra benefits are worth the extra cost.
  • Plan costs: To understand the full cost of your plan, you need to look at more than the monthly premium. Out-of-pocket costs include co-pays, co-insurance, and deductibles.
  • Yearly out-of-pocket max: Medicare Advantage plans also have a yearly maximum on out-of-pocket costs – something Original Medicare does not have.

Our Find a Plan tool makes comparing your Medicare plan options easy. Just enter your location, coverage start date, and hit Continue to review Medicare plans in your area.

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Donna Frederick

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.

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Last Updated 12/21/2018