Vision problems are a common health concern as you age. With the right health insurance, you can access the best vision care. Most older people have Medicare insurance, but does Medicare cover eye exams? The short answer is yes, but only for specific conditions.
What Does Medicare Cover?
Medicare is a government-funded health insurance plan for people aged 65 and older. It’s also available for younger people with disabilities and people with end-stage renal disease. There are four parts to the program.
Part A. Also called hospital insurance, Part A of Medicare covers hospital stays, hospice care, some home healthcare, and stays in a skilled nursing facility. These are inpatient services.
Part B. Known as medical insurance, Medicare Part B covers your outpatient medical services. These are your doctor’s appointments, urgent care clinic visits, tests, blood tests, and supplies that are medically necessary to diagnose or treat your condition.
Part B also covers preventive services, like vaccines, annual checkups, and screenings for cancer and other diseases. Medicare vision coverage falls under Part B preventive services, but only for some conditions. Part B also includes coverage for inpatient or outpatient mental health services, limited prescription drug coverage, ambulance services, and specific medical equipment.
Part C. Private insurance companies provide Part C coverage which bundles Parts A, B, and sometimes D with extra benefits you don’t get under traditional Medicare. These benefits can include dental coverage, vision coverage, gym memberships, over-the-counter drugs, and many other options. This plan is called Medicare Advantage. Medicare Advantage plans require you to get your health care from one of the providers in the plan’s network.
Part D. This section offers prescription drug coverage. All plans include a wide variety of drugs that most people take, but each has a list of specific drugs covered. If they don’t cover a drug, they often have a similar one available. Part D helps pay for your medications and can lower costs.
Does Medicare Cover Eye Exams?
Medicare vision coverage is limited to preventive screenings for some conditions and diagnosing tests under Part B insurance. Routine eye exams aren’t covered, though, so you’ll pay out of pocket for all fees unless you have a Medicare Advantage plan with coverage.
Medicare vision services covered under Part B are:
Tests for serious eye problems, like Glaucoma or Cataracts. If you have eye or vision problems, Medicare will cover the cost of tests to diagnose the condition, even if your results are negative.
Yearly glaucoma test.Glaucoma is a group of eye conditions where the optic nerve in the back of your eye becomes damaged. You’re more likely to get glaucoma when you’re older, and if you have a family history of glaucoma, you have diabetes, or you’re African American or Hispanic. Part B covers a yearly glaucoma test if you have a high risk of getting the condition.
Yearly diabetes-related exams. Diabetes can cause health complications, including a vision problem called diabetic retinopathy. High blood sugar over time damages the blood vessels in your eye, causing them to swell, leak, or close and affect your eyesight. If you have diabetes, Part B will cover a yearly exam to check your eyesight and screen for diabetic retinopathy.
Macular degeneration screening. Macular degeneration happens when a part of your retina, called the macula, becomes damaged. It causes loss of central vision and is a common cause of vision problems in older people. With Medicare Part B, you have coverage for preventative screening and some diagnosing tests for macular degeneration.
What Does Medicare Cover for Eyes?
Medicare doesn’t cover glasses or contacts unless you have extra benefits under a Medicare Advantage plan. Without Part C, you pay for 100% of the costs of contacts or eyeglasses. Original Medicare does have some other specific vision benefits, though.
Cataract surgery. Medicare Part B will cover surgery to correct vision problems from ongoing eye conditions, like cataract surgery. Medicare will only cover this surgery if you have a traditional or laser surgery, though.
Glasses after cataract surgery. Once you have cataract surgery, Medicare Part B will pay for one set of contact lenses or standard eyeglasses frames. You can get upgraded frames, but you’ll have to pay the extra cost. The eyeglasses or contacts supplier must also be Medicare-approved for your products to qualify.
Other services under Medicare Advantage. Some Medicare Advantage plans offer routine exams, eyeglasses and contacts, eye care supplies, and other tests and treatments.
The specific coverage details are different depending on the plan. You’ll want to check the details to understand what kind of vision coverage you’re getting.
Medicare Vision Services Fees
While you can usually get Medicare Part A for free based on your tax history, you must pay Part B premiums, even if you don’t use it. Plus, Part B includes other fees, so your Medicare vision services aren’t totally free.
On top of these monthly premiums, you also have to pay a yearly deductible and coinsurance. This means you pay a certain amount for services in the year, and Medicare only starts paying once you reach that threshold. After you pay the deductible, you’ll also have to pay for 20% of each vision service you access.
Your doctor’s status with Medicare can affect your costs, too. For example, if you use a doctor who doesn’t work with any Medicare program, you’ll have to pay all the costs directly, and Medicare won’t pay for any.
Some doctors will accept the Medicare rate on a case-by-case basis, but they might make you pay the entire amount upfront instead of waiting for Medicare to pay its share. You can submit those claims to Medicare for reimbursem*nt, but your doctor might not help you or submit claims on your behalf. Your doctor can also charge up to an extra 15% of the Medicare amount.
