Most seniors need regular eye care, but how do they get it covered by Medicare?
Eye health is an essential part of overall well-being for anyone. However, Medicare and vision benefits can be a confusing subject. How your insurance treats routine vision care depends on several factors, including the type of Medicare plan you have and the kind of exam you need. Knowing how your Medicare plan works is key to getting the best coverage for your vision needs.
In this article, we will uncover when Medicare will cover you—plus how much it will cover you—and when Medicare won’t. Let’s jump in.
Does Medicare Cover Routine Eye Exams?
For most seniors, a routine vision exam is not covered by Original Medicare. An annual exam, whether or not you already have prescription lenses, is not part of the Medicare package. There are exceptions for people who are more susceptible to vision issues.
An annual eye exam is covered through Original Medicare for patients with a high risk for certain eye diseases, or other mitigating factors includes:
- Cataracts screening and treatment
- Glaucoma screening and treatment
- Macular degeneration screening and treatment
- Eye exams for diabetes-related complications
- Eye prosthesis
- Other pre-existing eye conditions
For everyone else, you can get vision coverage through a Medicare Advantage plan, also known as Medicare Part C, or a stand-alone dental insurance plan. Medigap does not offer regular vision care.
If you choose to use a Medicare Advantage plan, be sure you understand precisely how and when your vision needs are covered. Not all Medicare Advantage plans include comprehensive vision comprehensively.
Does Medicare Cover Cataracts?
All seniors are covered for cataracts—screening and treatment. Original Medicare will cover 80 percent of the costs associated with cataract surgery, and it will cover one pair of basic corrective lenses—eyeglasses or contact lenses. If you have a Medicare Advantage plan or Medigap, you may have additional financial support for the procedure. If you have Medicare Part D, you may have additional support to pay for prescription drugs needed post-operation.
To learn more about cataracts coverage, please read our full article about how Medicare covers cataracts surgery.
Does Medicare Cover Glaucoma Care?
If you are in a high-risk category for glaucoma, Medicare will cover the screening and treatment of glaucoma up to 80 percent of costs. It’s critical, if you are high risk, to get screenings at least once a year. Glaucoma symptoms are usually not detected until the disease is advanced. Without care, glaucoma will cause blindness.
People who are at high risk for glaucoma include:
- African Americans over 50
- Hispanic Americans over 65
- People with diabetes
- People with a family history of glaucoma
Annual screens are covered up to 80 percent under Original Medicare. Additional benefits can be provided through a Medicare Advantage plan or supplemental insurance.
Does Medicare Cover Macular Degeneration?
Age-related macular degeneration is a significant cause of vision loss in people over the age of 50. It’s important to note that macular degeneration screening will only be covered if your eye doctor recommends it as medically necessary. Having a good relationship with your general practitioner is key to getting your screening covered.
There are some well-studied risk factors for macular degeneration:
- Caucasians over the age of 50
- Current smoker or history of smoking
- History of high blood pressure
- Family history of macular degeneration
Medicare covers macular degeneration screening and treatments up to 80 percent of costs. If you have a Medicare Advantage plan or supplemental insurance plan, you may be covered for more.
Does Medicare Cover Eye Exams for People with Diabetes?
Because people with diabetes have a higher probability of developing specific vision issues, Medicare does cover an annual comprehensive eye exam. Diabetic retinopathy—a condition that affects blood vessels in the eyes—and diabetic neuropathy—a condition that affects the nerves in the eyes—are covered by Medicare.
Again, Original Medicare covers 80 percent of the costs associated with eye care for diabetic seniors. Seniors can get additional coverage through a Medicare Advantage plan or Medicare supplement insurance.
Always talk to your optometrist or ophthalmologist about the best way to prevent and screen for vision issues.
FAQ: Medicare Eye Exam Coverage
How does Original Medicare cover eye care?
Most of the time, your vision care will be covered by Medicare Part B. Part B covers medically necessary services and supplies plus preventive care. You will be responsible for covering some of the costs up to your Part B deductible. It is possible to get 100 percent of preventative care, such as a glaucoma test, paid for through Medicare coverage if that doctor accepts “assignment.” Assignment, according to Medicare.gov, is when your doctor agrees to be paid directly through Medicare (at Medicare rates) without asking you for coinsurance or copayment.
Does Medicare cover dry eyes?
Treatment for dry eye syndrome may be covered by Medicare prescription drug coverage—depending on the drug plan you’ve chosen. The most common treatment plan includes prescription eye drops. When undergoing treatment for dry eye syndrome, be sure to ask your doctor about the risks and benefits of your many choices in treatment. Also, be sure to inquire about how your drug plan covers different eye drops to find the right one for your budget.
Does Medicare cover eye prosthesis?
If you have an eye prosthesis, Medicare will cover some of the costs associated with your eye care. This includes care for the prosthesis itself, like polishing and prosthesis replacement as much as once every five years.
Does Medicare cover eyeglasses?
In most cases, Medicare does not cover eyeglasses. However, one basic pair of glasses or contact lenses is covered after cataract surgery—up to 80 percent of costs. Other eye care may make you eligible for eyeglasses coverage. Be sure to read your plan carefully. If you’ve purchased additional health insurance, you may be eligible for extended vision care and eyeglasses coverage. Be sure to check all your health plans before you buy your glasses.
How can I get the best vision coverage with Medicare?
If you’re looking for more comprehensive coverage than Original Medicare, you should look into supplemental insurance or a Medicare Advantage plan. Medicare Advantage plans must cover everything at least as much as Original Medicare. Many Advantage plans cover additional health-related needs, like vision care.
Conclusion: There’s More to Medicare than Original Medicare
If you need more comprehensive vision coverage than what Original Medicare allows, you can buy coverage on the open market. Thousands of Medicare Advantage plans exist, not to mention all the supplemental coverage options available. Long story short: if Original Medicare doesn’t work for you, find a plan that does.