Does Medicare Cover Eye Exams?

As people grow older, it’s common for them to suffer from vision-related problems. With Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage...., you have coverage for all of the routine checkups and preventative care you need. But what about your eyes? If you are wondering if your medicare benefits cover visits to the eye doctor, you might be surprised by the answer.

Key Takeaways

Routine eye exams are used to check a person’s vision for disease and deterioration.
Original Medicare doesn’t cover routine eye exams for eyeglasses or contact lenses.
With Original Medicare, you pay 100% for eye exams and your corrective lenses.
Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare... will only cover eye exams if they are a part of medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.... treatments, such as for diabetic retinopathy, glaucoma, and age-related macular degeneration.
Some Medicare Advantage Plans offer routine vision care and corrective lenses.
MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage.... policies are available to help with the costs of eye exams when Part B provides coverage for them.

What Are Eye Exams?

An eye exam is several diagnostic tests used to assess a person’s vision and evaluate any early signs of eye diseases or damage to the eyes. These different tests are each used to evaluate different aspects of a person’s vision and create a clear picture of their overall eye health. Getting routine eye exams helps eye doctors detect early warning signs of deterioration and start preventative care as soon as possible.¹

Age-Related Eye Problems

As we age, there are certain eye conditions people need to be aware of. Some age-related eye conditions include:

Presbyopia–the inability to read the fine print (or see small objects clearly)

Glaucoma–increased pressure inside the eye that can lead to blindness

Cataracts–Cloudy buildup in the front part of the eye that can lead to vision impairment

Retinal Disorders–problems with the retina that can interfere with the ability to transfer images

Eye Injuries

So what does Medicare have to do with all of this? If our eyes will face inevitable problems with age, shouldn’t all Medicare plans cover all routine eye exams?

When Does Medicare Cover Eye Exams?

Original Medicare (Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care.... and Part B) does not cover routine eye exams. For most regular eye health checkups, you will have to pay 100% out of pocket or buy additional coverage.²

Thankfully, Medicare Part B does cover certain exams for age-related eye problems. Glasses, while important, are not as urgent as a glaucoma exam, and Medicare accounts for these specific needs as we age.²

Medicare covers eye exams and, in some cases, surgery for these conditions:

Diabetic Retinopathy Screening

People with diabetes may develop diabetic retinopathy, which is damage to the blood vessels in their eyes that will lead to vision deterioration³. Medicare Part B covers annual vision exams for people who are at increased risk for diabetic retinopathy screening.⁴

It’s important to know that Medicare Part B will only pay for this screening if:

You are enrolled in Part B.
You have a diabetes diagnosis.
An eye doctor performs the exam.

Glaucoma Screening Test

Glaucoma is the gradual deterioration of optic nerves caused by excess fluid build-up in the eye. This causes deteriorating vision that results in blindness if not treated⁵.

Medicare Part B covers glaucoma screening. The program only covers the cost once a year and only if you’re at high risk for glaucoma.⁶

You’re considered high risk for glaucoma if you:

Have diabetes
Have a family history of glaucoma
Are African American and 50+ years old
Are Hispanic American and 65+ years old

If you fall into the risk factors above, Medicare may cover glaucoma screening or a glaucoma test as long as it’s performed by an eye doctor or an eye doctor supervising someone who is performing the exam.

If the glaucoma test is performed in a hospital, you will have to pay the copaymentA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.....

Macular Degeneration Tests

Age-related macular degeneration (AMD) is a chronic condition that causes blurriness or blind spots in your field of view. AMD is usually caused by a malformed blood vessel that leaks fluids into the macula, the central vision area of the retina.⁷

Those who may have signs of macular degeneration may receive coverage for the macular degeneration test for diagnosis. Those eligible for the test may need to pay 20% of the Medicare-approved amountA Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges. What Does Medicare-Approved Amount Mean? A Medicare-approved amount is... if they have reached the deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share..... Just like with diabetic retinopathy screening, if the macular degeneration test is performed in a hospital setting, the patient may need to pay a copay.⁸

Eye Injuries and Diseases

Medicare will cover an injury to your eye just as it would an injury anywhere else. It also covers eye diseases and treatments such as ranibizumab (Lucentis), aflibercept (Eylea), and ocular photodynamic therapy.⁹¹⁰

Medicare Advantage Plans

Although Original Medicare does not cover routine vision care, including eye exams, many Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B).... do. It is the additional benefits offered, like dental, vision, and hearing that give them an advantage over Original Medicare. In addition to routine vision care, many plans cover corrective lenses, as well.

Medicare Advantage plans are Medicare-approved plans offered by private insurance companies. If you need health insurance that offers vision care, use our plan finder tool to explore options where you live. Many plans also cover dental, hearing, and prescriptions, too.¹¹

Vision Coverage through Medicaid

If you have both Medicare and MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States.... benefits, in most states you can get routine eye exams and other vision benefits through Medicaid, including your preventive care and additional benefits. Curious if you qualify and enrollment procedures? You can learn more about how to qualify for both Medicare and Medicaid in this article.

In Summary

For those who are seeking coverage for routine eye exams, Medicare will not provide it unless you are suffering from a major eye condition. This is unfortunate, as early detection and preventative care can be crucial to preventing vision damage.

If you want Medicare to cover the costs of your vision services, a Medicare Advantage plan would be your best option. Compare the costs and the benefits of Orginal Medicare vs Medicare Advantage when considering how much vision care you need.

The tools you need to find these plans are all available on MedicareWire. Don’t wait until your primary physician sees that you have eye problems. If you are wondering, “Does Medicare cover eye exams?” The answer is yes, but you need to choose the right plan to get routine vision care.

Citations

1
Mayoclinic.org, “Eye exam“, Accessed November 3, 2021
2
Medicare.gov, “Eye exams (routine)“, Accessed November 3, 2021
3
Mayoclinic.org, “Diabetic retinopathy“, Accessed November 3, 2021
4
Medicare.gov, “Eye exams (for diabetes)“, Accessed November 3, 2021
5
Mayoclinic.org, “Glaucoma“, Accessed November 3, 2021
6
Medicare.gov, “Glaucoma tests“, Accessed November 3, 2021
7
Mayoclinic.org, “Wet macular degeneration“, Accessed November 16, 2021
8
Medicare.gov, “Macular degeneration tests & treatment“, Accessed November 16, 2021
9
oig.hhs.gov, “Review of Medicare Part B Claims for Intravitreal Injections of Eylea and Lucentis“, Accessed November 23, 2021
10
CMS.gov, ““, Accessed November 23, 2021
11
Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 16, 2021