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If you wear glasses and have Original Medicare (Part A and Part B), the question “does Medicare cover eye exams” matters a lot. Even if you currently don’t need prescription eyewear, there are a number of eye conditions that affect people as they age. According to the National Institutes of Health’s National Eye Institute, older adults are susceptible to age-related macular degeneration, cataracts, dry eyes, glaucoma, and low vision.
This article explains how Medicare treats eye exams and coverage for conditions and diseases of the eye.
When most people ask, “does Medicare cover eye exams,” they’re referring to routine vision checks. Unfortunately, under Original Medicare, there is generally no coverage for annual eye exams to check your vision and prescribe corrective glasses or contact lenses.
Part B does, however, cover eye exams and other eye tests under certain situations or if you have specific risk factors for disease. You need to see an eye doctor that accepts Medicare assignment to be covered.
If you have diabetes, Part B generally covers an annual exam for diabetic retinopathy if it’s performed by a doctor licensed to perform the test in your state. You pay 20% of the allowable charges after you meet your Part B deductible. Note, however, that Medicare covers this test just once per year, even if your doctor recommends it more often.
Medicare Part B generally covers an annual glaucoma exam by a licensed eye doctor if you have any of the following risk factors for the disease:
You pay 20% of allowable charges after you meet your Part B deductible.
If you have macular degeneration, or your doctor suspects you do, Medicare Part B generally covers eye exams and tests to diagnose the disease, related doctor visits, and certain injectable drugs used to treat macular degeneration.
Part B generally covers allowable charges at 80% after your deductible is met.
Medicare typically pays allowable charges related to diagnosis and treatment of cataracts, including cataract surgery. You’re responsible for the Part A deductible if your surgery requires a hospital stay, and your Part B deductible, plus your 20% coinsurance for covered outpatient services.
If you have cataract surgery with an intraocular lens implant, Part B usually pays for one pair of prescription eyeglasses or contact lenses after your surgery.
If your eyes are damaged in an accident or injury, Medicare usually pays for diagnostic eye exams and tests to determine the nature and extent of the injury.
Generally speaking, Medicare covers medically necessary eye exams to diagnose and treat any diseases or conditions of the eye, such as an eye infection or a foreign body in your eye.
In most cases, the only way to get Medicare coverage for routine eye exams is through a Medicare Advantage plan. Medicare Advantage plans are offered by private insurance companies and have slightly different rules than Original Medicare.
Under federal law, all Medicare Advantage plans must offer, at a minimum, all the benefits available under Medicare Part A and Part B. Once those minimums are met, Medicare Advantage plans can offer other additional benefits that make them more attractive to their members. For example, many Medicare Advantage plans offer benefits for routine annual eye exams. You may have to pay a copayment or coinsurance amount for these exams, and depending on the plan you choose, you may have to see an eye doctor that participates in your plan’s network.
If you need prescription eye drops or other medications for an eye condition, most Medicare Advantage plans also include Part D coverage for prescription drugs. Some plans even include benefits or discounts for certain over-the-counter medications and drops.
Many Medicare Advantage plans also cover prescription eyeglasses and contact lenses. You may have to pay a copayment or coinsurance amount, or the plan may simply pay a flat fee amount toward the purchase of corrective eyewear.
Not all Medicare Advantage plans offer routine eye exam benefits, so if this coverage is important to you, be sure to check plan details before you decide on the right plan for you. Remember that not all benefits are available with all plan types, and not all plans are available in all areas. You must continue to pay your regular Part B premium every month in addition to your Medicare Advantage plan premium if you choose Medicare Advantage.
Do you have any questions about your Medicare coverage of eye exams? Feel free to enter your zip code on this page to browse Medicare plan options in your area.
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