Original Medicare (parts A and B) does not cover routine eye exams. However, exams for certain conditions may be covered, including those for glaucoma, macular degeneration, and diabetic retinopathy.
Eye exams are important tools for identifying potential problems with vision. This is particularly important as we age and the risk of eye conditions like cataracts and glaucoma increases.
Medicare does cover some types of eye exams. But what kinds of eye exams are covered? And what parts of Medicare cover them?
This article provides answers to these questions and more.
Generally speaking, Original Medicare (parts A and B) does not cover routine eye exams. However, some types of other eye exams may be covered. These can include:
Eye exams for those with diabetes
People who have diabetes can develop a condition called diabetic retinopathy. It happens when elevated blood sugar levels lead to damage of the blood vessels supplying your retina. This condition can cause vision loss.
If you have diabetes, Medicare will cover eye exams to detect diabetic retinopathy once per year.
Glaucoma tests
Glaucoma is a condition that involves damage to the optic nerve, potentially causing vision loss. As you get older, your risk for glaucoma increases.
Medicare covers tests for glaucoma once every 12 months for individuals who are at high risk for developing glaucoma. You may be at high risk if you:
- are over 60 years old
- have a family history of glaucoma
- have diabetes
- are very nearsighted or far-sighted
- have high eye pressure
- have a thin central cornea
- use steroid medications
- have had a previous eye injury
Research shows there’s a higher prevalence of glaucoma diagnoses in people of African, Hispanic, and Asian descent.
Macular degeneration tests and treatment
Macular degeneration is an age-related, progressive condition that leads to central vision loss. This means it affects what you see directly in front of you. The condition can affect activities like driving and reading.
Medicare may cover some diagnostic tests and treatments if you have age-related macular degeneration. This can also include things like some types of injectable drugs.
Cataract surgery
Cataracts occur when the lens of your eye becomes clouded. Since the lens helps your eyes focus, the presence of cataracts can make your vision blurred, cloudy, or faded.
Medicare covers some aspects of cataract surgery, including:
- the placement of an intraocular lens (IOL), a small clear disc that replaces a lens that has become clouded with cataracts
- a pair of eyeglasses or contact lenses following each IOL insertion surgery
- the costs of facility and provider services for the placement of an IOL
Medicare only covers the placement of a conventional IOL.
Some types of IOL correct astigmatism or presbyopia. Medicare will not pay for facility or provider services related to insertion or adjustment of these specific types of IOLs.
There are several parts of Medicare that may cover vision care.
Medicare Part A
This part covers stays in the hospital or other inpatient facilities, such as skilled nursing facilities. If an eye condition requires admittance to the hospital, Part A may cover your stay.
Most people don’t pay a premium for Part A. When you’re in an inpatient facility, the amount you pay in coinsurance is based on the type of facility you’re housed in and the length of your stay.
Medicare Part B
Medicare Part B covers the following:
- doctor-related services
- outpatient care
- preventive care
- medical devices
After meeting a yearly deductible, you’re typically responsible for 20% of the Medicare-approved costs. This part of Medicare covers the eye exams that we’ve discussed above, which include:
- eye exams for people with diabetes once per year
- glaucoma testing in people at high risk for the condition once every 12 months
- age-related macular degeneration testing and treatment
- placement of conventional IOLs during cataract surgery, eyeglasses or lenses after the procedure, and facility and service costs
Medicare Part C
You may also see Medicare Part C referred to as Medicare Advantage. Private companies with Medicare approval provide these plans.
Part C offers all the benefits of parts A and B. Most Part C plans include Part D (prescription drug coverage) as well. Some Part C plans offer additional benefits like vision and dental.
It’s likely that a Part C plan that includes vision benefits will include benefits such as:
- routine eye exams
- eyeglass frames and lenses
- contact lenses
The premiums, costs, and types of services Part C provides can vary by plan. It’s important to carefully compare Part C plans before selecting one.
Medicare Part D
Medicare Part D is an optional plan that includes prescription drug coverage. Like Part C, Part D is offered by private companies that have been approved by Medicare.
Medications required for eye care may be covered under Part D. Examples include medications for glaucoma, dry eye syndrome, or eye infections.
Premiums, copayments, and the types of drugs that are covered can be different depending on the plan. Compare Part D plans to ensure the medications you need are covered.
Overall, the cost of an eye exam can depend on several factors, including:
- Your type of insurance: What’s covered can vary by your specific plan.
- Charges from the doctor or facility you visit: Some doctors or locations may charge more than others.
- What types of tests are performed: Specialized tests or getting fitted for eyeglasses or contact lenses may cost more.
To help estimate the costs, contact your insurance provider to find out what services are covered. For Medicare, Part B will cover select types of eye exams, while Part C coverage will depend on your specific plan.
Next, ask about the total cost of the exam as well as what tests are included when selecting a doctor or facility. You can use this information with the information from your insurance provider to estimate how much you’ll owe.
If you’re concerned about the costs of eye exams or eye care, there are a variety of resources available to you. The National Eye Institute has a list of programs
So how do you know which plan is right for you if you know you’ll need an eye exam? It’s important to consider your specific needs when selecting a plan.
Part B will only cover certain types of eye exams, often for people who are at high risk for certain conditions. If you’re in one of these groups, Part B may be sufficient to meet your needs.
Additionally, Part B covers the placement of IOLs in cataract surgery. If you know that you’ll need cataract surgery in the future, you may want to select a Part B plan.
If you know you’ll need routine eye exams, eyeglasses, or contact lenses, you may want to look into a Part C plan. Many of these plans include vision benefits that are not included with just Part B alone.
If you use medication for an eye condition, such as glaucoma or dry eyes, consider enrolling in Part D. This can help cover the cost of these medications.
Tips for helping a loved one enroll in MedicareAre you helping a loved one enroll in Medicare? Follow the tips below:
- Know if they need to sign up: Individuals collecting Social Security benefits will be automatically enrolled in parts A and B when they’re eligible for Medicare. Those who are not collecting benefits will need to sign up starting 3 months before they turn 65.
- Be aware of the open enrollment period: This is when they can make changes to their coverage. It’s from October 15 through December 7 every year.
- Discuss their needs: Every person is different and has different health needs that may help inform the selection of a plan. For example, someone who wears eyeglasses or contact lenses may opt for Part C, which can provide coverage for these items.
- Compare different plans: If they’re interested in enrolling in Part C or Part D, compare several plans to find one that meets their specific financial and health needs.
- Provide information: Social Security may ask for some personal information as well as your relationship to the person you’re helping. Your loved one will need to sign the Medicare application themselves before it’s submitted.
Many older individuals use eyeglasses or contact lenses to help with their vision. In fact, a
However, Medicare Part B does not cover eyeglasses or contact lenses. Part B only covers these items if they’re provided following cataract surgery where an IOL is placed.
Many Medicare Part C (Medicare Advantage) plans have vision benefits that may cover eyeglasses and contact lenses. If you know that you’ll need these benefits, it may be a good idea to look into enrolling in a Part C plan.
Eye exams are an important first line of defense against conditions like glaucoma or cataracts. Timely identification and treatment can help prevent vision loss.
Medicare Part B only covers certain types of eye exams, mostly for individuals at high risk for certain conditions. Part B also covers some aspects of cataract surgery.
In addition to including coverage provided by parts A and B, Medicare Part C plans may have additional vision benefits. These can include services and products like routine eye exams, eyeglasses, and contact lenses.
When selecting a Medicare plan, carefully consider both your health and financial needs. You may need to compare several plans to find the one that’s right for you.