Is An Eye Exam Covered By Medicare

Is A Routine Eye Exam Covered By Medicare

Routine vision checks, annual eye exams, and eye tests for eyeglasses or contact lenses are generally not covered under Original Medicare .

However, Part B will cover routine eye exams and certain expenses if the procedure is deemed to be medically necessary health care services that a health care provider, using clinical judgment, would provide to a patient.

For example, if the patient has diabetes or is at risk for glaucoma they can go for an annual eye exam. Medicare Part B will also cover diagnostic tests and treatments for particular eye or vision diseases such as aflibercept, Lucentis, and ocular photodynamic therapy.

Part B will contribute toward one pair of corrective glasses or one set of contact lenses following cataract surgery to implant an intraocular lens.

Once the patient has paid the annual deductible , Part B will reimburse 80% of the Medicare-approved amount for the glasses.

You will only receive coverage if your treatment is approved and given by an eye expert who accepts Medicare. The remaining 20% will be paid by you.

Source: Pexels

What Is A State

A state-licensed doctor is a person licensed to practice medicine or osteopathic medicine and surgery in the state that they have been approved to operate in.

This will be covered under Medicare Part B, which means youll first have to pay your annual deductible. The patient will also have to pay 20% of the costs while Medicare covers 80%.

It is important to note that if your doctor suggests more tests, this service is only covered once a year.

Original Medicare Eye Services For Non

Original Medicare can also help seniors pay for some non-vision eye care. Part B beneficiaries who have lost an eye, for example, are covered for 80% of the cost of a prosthetic replacement. This artificial eye may be polished and resurfaced as needed, with a replacement authorized once every five years.

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Medicare Eye Exam Coverage

A simple vision test is included in the Welcome to Medicare preventive visit. Its covered by , but its offered only once and within the first year of Part B coverage.

Medicare does not cover routine eye exams for eyeglasses or contact lenses. However, a yearly eye exam is covered by Medicare Part B for those living with diabetes and diabetic retinopathy. Eye exams for diagnostic purposes, such as testing for glaucoma or macular degeneration, may also be covered.

You will have to pay 20% of the amount approved by Medicare for these services. Your Part B deductible will also apply. A copay will be charged if you get tested in a hospital outpatient setting.

Look For Optical Centers That Take Medicare

There are a few national optical centers that accept Medicare. The easiest way to check whether the provider of your choice accepts Medicare is to check its website to see if Medicare is listed as an accepted insurance plan. Also, be sure to check the service coverage to make sure your specific needs will be met at this specific establishment.

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Where Can I Learn More About Medicare And My Coverage Options

Eyecare is such an overlooked but important part of your medical care, and PolicyScout wants to ensure that you find the best coverage for your eyes.

If you are looking for up-to-date and accurate information about Medicare, Medicare Advantage, and Medicare Supplemental Insurance, head to PolicyScouts Medicare Hub to compare your options and find the best plan for you.

We can also connect you with some of the best Medicare Advantage providers in your area if youre ready to look into different Medicare Advantage plans.

If you are looking for more guidance, send your questions to or call us on to get personalized assistance from one of our skilled Medicare consultants.

Does Medicare Cover Diabetic Retinopathy

Diabetic retinopathy can damage blood vessels in the eye, causing vision problems and loss. If youve been diagnosed with diabetes, Medicare Part B will pay for one eye exam per year to get ahead of brewing eye problems. Youll still pay 20% of the Medicare-approved amount for your exam, and your Part B deductible will apply if you havent met it yet.

Treatment is often addressed at targeting the underlying condition diabetes and Medicare will provide coverage for the medical care necessary to treat diabetes. The newly signed Inflation Reduction Act limits insulin copays to $35 per month for Medicare Part D beneficiaries starting in 2023.

As is the case for other services, a Medigap plan can pick up some or all of the cost of the Part B deductible and coinsurance related to diabetic retinopathy testing, depending on the Medigap plan you have. And if you have a Medicare Advantage plan, your costs will depend on the plans benefit structure.

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Does Medicare Cover Glasses

Medicare doesnt usually cover eyeglasses or contacts, so youd have to pay 100 percent of the cost with the exception of certain eye conditions. In some cases, Medicare Part B can help you pay for corrective lenses if youve undergone cataract surgery to implant an intraocular lens.

After cataract surgery, you can receive up to one pair of eyeglasses with standard frames or one set of contact lenses. If youve had cataract surgery and require eyeglasses and other vision care, youd still have to pay 20 percent of the Medicare-approved amount and the deductible.

What Is A Cataract

A cataract is a clouding of the eyes lens and is the leading cause of vision loss and blindness worldwide. Cataracts can occur at any age due to its many different causes and can sometimes be present from birth.

It is estimated that 20.5 million Americans aged 40 years and older have cataracts in one or both eyes. The total number of people who have cataracts was estimated to increase to 30.1 million in 2020.

Eye Exam coverage from Medicare

The table below summarises the various types of eye diseases and what Medicare can do to help.

Source: Pexels

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Does Medicare Cover Ophthalmologists

An ophthalmologist is a medical professional that treats eye conditions. While they can provide vision exams for corrective lenses, they focus more on medical eye care and surgical processes. For example, they can perform surgery to correct crossed eyes or glaucoma and diagnose and treat eye conditions related to diabetes or other health conditions.

Because an ophthalmologist is focused on medical care instead of vision correction, your appointment is more likely to be covered by Original Medicare. However, Medicare will still need to deem the procedure or exam medically necessary. That means, for example, that cosmetic eye surgery will not be covered.

Medicare Advantage plans will also cover medically-necessary care from an ophthalmologist. However, you may get additional coverage for vision correction as well. It all depends on whats included in your Advantage plan.

When Medicare Pays For Eye Exams And Glasses

Medicare only covers medical eye exams and related treatments, with a few exceptions. Since Part A is your hospital coverage, coverage would only kick in if you suffer a traumatic eye injury or emergency that requires you to be admitted to the hospital. Most of your eye care will be covered by Part B.

Eye exams Medicare Part B covers

If you need a medical eye exam , your exam and care are covered by Part B.

Medicare Part B also covers cataract surgery, including the specific exams leading up to it. Heres when one of those previously mentioned exceptions appears: After cataract surgery, Medicare will cover one pair of conventional eyeglasses or conventional contact lenses after each surgery. This is the only time Medicare will pay for eyeglasses.

Medicare Part B also covers the following eye care services:

• An annual glaucoma screening for high-risk patients. You are usually considered high risk if you have a family history of glaucoma, are an African American over age 50, are a Hispanic American over age 65, or if you have diabetes.
• An eye prosthetic and certain maintenance of the prosthetic if you lose your eye due to trauma or surgical removal.
• Certain screenings, diagnostic tests, and treatments for age-related macular generation.
• Contact lenses used to treat a medical condition.

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Medicare Advantage Coverage For Eyeglasses And Eye Exams

While Medicare Parts A and B offer some limited, specific vision benefits, if you are interested in coverage for eyeglasses, contact lenses, or eye exams you may find benefit in a different plan. Medicare Advantage plans are offered through private insurance companies and cover all services that Medicare Parts A and B provide, with the addition of some benefits and/or savings. Medicare Advantage plans are known for providing coverage for vision, hearing, dental, prescription drugs and more in a single plan.

According to Kaiser Family Foundation , 98% of all Medicare Advantage plans offer coverage for eye exams and/ or eyeglasses. Its important to note that each plan is different. While many plans offer coverage, the level of benefit offered will likely vary depending on the plan. Some plans may cover the full cost of glasses or contacts, while others may have a maximum limit of coverage per year. Understanding the nuances of the plans that are available to you will help you choose a plan that suits your healthcare needs and goals.

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Does Medicare Cover Eye Exams For Glaucoma

Glaucoma can cause damage to the optic nerve due to high pressure in your eye. This is a medical condition that is important to catch early and is one of the leading causes of blindness in those over age 60.

Original Medicare does cover an annual test for glaucoma if youre in a high-risk category for the disease.

High risk includes:

• Having a family history of glaucoma
• Being an African American over age 50
• Being a Hispanic over age 65

Medicare Advantage will also cover a glaucoma screening once a year if youre in a high-risk category. You may also be covered for screening in other circumstances. Youll want to check with your specific plan for details.

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How Much Does An Eye Exam Cost With Medicaid

Eye exam copays can cost from $0 to $15, depending on your state. Most states also have different copays for children and adults.

Depending on the state, your copay also could cover eyeglasses, or there could be a separate fee for your spectacles. Check your state’s Medicaid vision benefits so you will know what’s covered and your expected costs.

What Vision Services Does Original Medicare Not Cover

Medicare’s vision coverage is primarily limited to treating specific conditions. You can, however, purchase ancillary insurance to provide dental, vision, and hearing coverage.

You’ve likely already had ancillary insurance if you’ve ever been insured through an employer it would have been the secondary coverage options you chose to receive vision and dental benefits.

In addition to routine dental and hearing care, ancillary insurance usually covers contact lenses, eye exams, eyeglass frames, and prescription lenses. Unlike Medicare, you can add beneficiaries to your secondary coverage, meaning you won’t be the only one reaping the benefits.

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Will Medicare Cover Treatment For Glaucoma

Glaucoma is a disease that damages the optic nerve, potentially resulting in vision loss. Medicare Part B will cover annual glaucoma screenings for those considered high-risk, including diabetics and older Americans with a family history of the disease. African Americans aged 50 and older, and Hispanic individuals aged 65 and over are also considered high-risk.

Youll still be responsible for your Part B deductible and if youve already met the deductible, 20% of the cost of your exam. .

Glaucoma treatment is generally covered under Medicare. Outpatient laser surgery falls under Part B, and eye drops to address the condition fall under Medicare Part D. Your out-of-pocket costs associated with your drops will depend on your Part D plans formulary.

Because Medicare Advantage is required to provide coverage for the conditions that are covered by Original Medicare, it also covers glaucoma screenings and treatment. But because Medicare Advantage plans can design their own benefits, the out-of-pocket costs can vary considerably from one plan to another.

Medigap, meanwhile, can cover some or all of the costs associated with your glaucoma screening and treatment under Original Medicare by picking up the tab for your deductibles and coinsurance. And if you have supplemental coverage provided by an employer, your out-of-pocket costs will depend on the specifics of the plan.

What Is Medicare Coverage For Eyeglasses

As we already mentioned, Part A and Part B of Original Medicare do not cover the cost of glasses or contact lenses. Unfortunately, retirees should pay out of pocket for them.

However, Medicare Advantage plans often cover the cost of glasses or contact lenses. If you are enrolled in a Medicare Advantage plan, you should check with your plan provider to see available coverage. When you are not enrolled in a Medicare Advantage plan, there are some other options available to help cover the cost of glasses or contact lenses. For example, some private insurance plans offer vision coverage, and you can also purchase a standalone vision plan to help cover the costs.

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Does Medicare Cover Lasik Surgery

Medicare Part A and Part B do not cover Lasik procedures unless a physician deems them medically necessary. Medicare does not cover the procedure for the sake of standard vision correction.

One example of Lasik coverage by Medicare is for a traumatic injury in which Lasik could be a beneficial treatment. Lasik is a procedure that treats farsightedness, astigmatisms, and nearsightedness.

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Lasik surgery is the most common eye surgery, proven to drastically improve eyesight immediately following the procedure. It is a surgery that uses a laser and is virtually painless for patients. In most cases, Medicare will not pay for the eye exam prior to a Lasik procedure.

What Is The Medicare Coverage For Eye Care And Eyeglasses

Understand Medicare coverage, costs, and options for vision care and corrective lenses.

Contributing expert:Kelly Blackwell, Certified Senior Advisor®Updated: April 16, 2022

Kelly Blackwell

Kelly Blackwell is a Certified Senior Advisor ®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.

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Vision Screening And Risk Factors

Although Original Medicare doesnt cover routine vision care, Medicare Part B covers one preventive vision screening per year for those at high risk for glaucoma. According to the Centers for Medicare & Medicaid Services, African-Americans aged 50 and older, Hispanic Americans aged 65 and older, people with diabetes, and people with a family history of glaucoma are at high risk for the disease. An eye doctor whos legally permitted by your state must perform the exam.

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Who Accepts Medicare For Eyeglasses

There are several optometrists, ophthalmologists, and vision centers that accept Medicare. You can find national and regional retailers accepting Medicare when you check in for an eye exam or get a new pair of glasses. You can also ask for a list of accepted insurance plans from your chosen establishment or optometrist. Some of these establishments also allow for online ordering and contactless pick-up or delivery of your glasses.

Does Medicare Cover Dry Eyes And Allergies

Though having dry eyes wont necessarily impact your vision, it can be a painful condition that affects your quality of life. Medicare will generally cover an exam to diagnose the problem since its not considered routine, at which point youll be on the hook for 20% coinsurance after youve met your Part B. Your Part D plan might also cover medication to treat the condition, though in some cases, over-the-counter treatment will suffice. Youll get similar coverage with a Medicare Advantage plan, and Medigap can help with your out-of-pocket costs if you have Original Medicare.

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Does Medicare Cover Macular Degeneration Eye Exams

If you have, or your doctor suspects you have Macular Degeneration, often called Age-Related Macular Degeneration , Medicare Coverage Part B typically covers exams, tests, doctor visits, and certain prescribed drugs related to the disease.

After your Part B detectable has been met, 80% of the allowable charges will generally be covered.

Best Medicare Plans For Vision Care

Now that you know what Medicare does and does not cover when it comes to vision care, which plans are the best? As we previously stated, Original Medicare does not cover routine eye exams for corrective lenses. Enrollment in a Part C plan is required to obtain this type of coverage. Thankfully, the majority of Part C plans include some type of vision coverage along with many additional benefits. The specifics of deductibles and coinsurance payments vary, and you should select the plan that best fits your needs.

When it comes to Medicare options, the two best plans currently available are with United Healthcare and Kaiser Permanente. Both of these plans cover routine annual exams. In addition, they provide at least $200 in annual benefits for prescription lenses like glasses or contacts. The Kaiser plan even has a premium plan that provides a $400 allowance for lenses.

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