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.
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:
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.
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:
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.
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.
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:
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.
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.
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:
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.
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.
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.
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