Does Medicare Cover Eye Exams

Medicare doesn’t provide vision insurance coverage for eye exams or other eye-related procedures with a few exceptions for what is deemed medically necessary. For example, patients that have glaucoma, diabetes, or macular degeneration may have some procedures covered.

Medicare Part B covers exams for people with diabetes to test for diabetic retinopathy once a year. Only certain doctors are legally permitted to administer this exam from state to state. After the deductible is met for Part B, the patient is responsible for 20% of the approved amount.

Conventional routine eye exams cannot detect diabetic retinopathy. Dilated eye exams performed by an ophthalmologist or optometrist properly licensed to give the exam can detect it and allow for the doctor’s diagnosis. Severe diabetic retinopathy, which requires invasive treatment, can only be performed by an ophthalmologist. Treatments may include injections, eye surgery, or laser therapy.

Glaucoma testing is available for specific groups under Medicare Part B. The tests are provided every 12 months for those deemed high risk.

According to Medicare, these patients are at higher risk of glaucoma:

• Hispanic men and women 65 and older.

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• African American men and women 50 and older.

• Patients with a family member with glaucoma.

• Patients who have diabetes.

After the deductible is met for Part B, the patient is responsible for 20% of the approved amount for glaucoma testing.

Macular degeneration treatments and tests may be covered under Medicare Part B. Medicare may cover injected drug treatment and certain diagnostics if the patient has age-related macular degeneration. As with the other exceptions for vision care, Macular degeneration also carries a 20% responsibility for the approved amount after meeting the deductible.

Because prices for treatments and diagnostics fluctuate in different states and by different doctors, Medicare recommends that patients talk to their healthcare providers about costs. Factors that can impact price variance include:

• Where the patient gets the testing or service.

• The type of facility, doctor’s office, hospital, etc.

• If the patient’s doctor accepts the assignment.

• How much the doctor charges.

• Other insurance carried by the patient and what that covers.

Cataract surgery may also be covered by Medicare Part B. It can help cover the costs for corrective lenses required after the implantation of intraocular lenses. This can include glasses if lenses are not preferred.

Parts of Medicare and Approved Eye Exams and Procedures

Part A, considered hospital insurance, does not cover contact lenses, glasses, or routine exams. It can cover vision care for medically necessary procedures. This can include injuries or vision problems that require being hospitalized.

Part B, which is considered medical insurance, as mentioned, doesn’t cover eye examinations, save for a few exceptions. High-risk patients and those with glaucoma have 80% of some services covered. Medically necessary procedures related to cataract surgery may also be covered.

What is often referred to as Part C, Medicare Advantage, is a way to receive add-on benefits. This service can cover some of what Medicare does not in terms of dental, vision, and hearing.

Additional coverage from other providers often covers eye exams, glasses, and corrective lenses. Medigap, which is Medicare supplemental insurance, is a way to cover costs not covered by Original Medicare.

Vision providers that accept Medicare can be located on the website. The database is accessible under the find care providers link.

Medicare Advantage plans are typically the way to go when looking for general vision care coverage. Several trusted institutions offer these programs, including UnitedHealthcare, Blue Cross BlueShield (Anthem,) Aetna, and Humana. Each plan has different coverages and costs. Medicare Advantage plans can be found on with just a zip code.

One area in which Medicare does offer the most benefits is the services of ophthalmologists. These doctors are specialists in eye disease treatment and in surgical and medical concerns of the eyes. While Medicare will not pay for a routine exam, medical and surgical cases can be covered by an ophthalmologist. Prior authorizations and referrals may be required. It’s suggested to check with the site or speak with a representative to determine what is covered.

Medicare does not cover eye exams. According to Medicare—and most other insurance companies—eye exams are not considered a necessary part of the health care routine for people 65 years or older. This means that if you’re 65 or over and need an eye exam, you will have to pay for it out of your pocket. Some might argue that this is unfair, given that age can significantly contribute to vision loss, and there are some exceptions.

However, Medicare is not the only source of health care coverage in the country. Vision services may still be covered if qualified for gap insurance like Medicare Advantage. So, if whether your eye exam will be covered under your current health care plan is a concern, speak with your doctor or insurance company to see if it’s a covered service.