Summary: Medicare provides limited coverage for services and supplies related to vision care. In this article, we’ll review which preventative and medically necessary vision services are covered under Original Medicare. We’ll also explore other options Medicare beneficiaries have for receiving coverage for routine eye care. Estimated Read Time: 7 min
Why Vision Care is Important for Medicare Enrollees
Eye and vision care is an essential component to healthcare that shouldn’t be overlooked. The American Foundation for the Blind states that an estimated 9.2 million adults over age 65 have reported experiencing vision loss. In fact, age-related eye diseases are primarily the leading cause of blindness and low vision in the United States. This includes diseases such as age-related macular degeneration, cataracts, diabetic retinopathy, and glaucoma.
Early detection and treatment of many eye diseases can significantly reduce the risk of vision loss or damage to the eye. This is why it’s important for Medicare enrollees, especially those with a chronic condition that increases their risk of eye diseases, to get the vision care they need.
Medicare has limited coverage when it comes to vision services and items. Below, we’ll discuss which services are covered by Medicare and how you can supplement your coverage to get the care you need without breaking the bank.
Does Medicare Cover Vision Services?
Medicare provides limited coverage for vision services. Original Medicare does not cover routine eye exams or glasses/contacts used for correcting refractive errors. However, Medicare will provide coverage for eye exams and treatment related to cataracts, glaucoma, and diabetic retinopathy. Medicare will also cover medical emergencies related to the eye, such as surgery for retinal detachment.
Vision Services Medicare Covers:
- Glaucoma screenings
- Eye exams for diabetic retinopathy
- Eyeglasses or contact lenses following an implant of an intraocular lens
- Medical emergencies or surgeries related to the eye, such as retinal detachment
- Prosthetic eye (when ordered by your doctor)
Medicare Does Not Cover the Following Vision Services and Items:
- Routine eye exams (eye refractions)
- LASIK eye surgery
- Contact lenses or eyeglasses*
- White canes or service dogs for blind individuals
- Any vision assistive equipment or low-vision devices
*There are exceptions, see below for more information.
Of the vision services that Medicare does cover, most are covered under Medicare Part B. However, any eye surgeries or procedures performed in an inpatient hospital setting will be billed under your Medicare Part A. Prior to a procedure or exam, you can ask your provider whether or not your service will be covered under Medicare and how it will be billed.
Medicare Coverage for Eye Exams
Medicare does not cover routine eye exams for prescription eyeglasses or contact lenses (these exams are sometimes referred to as “eye refractions”). Unless you have additional vision coverage outside of Original Medicare, you will pay all costs for routine eye exams. Original Medicare does, however, provide coverage for eye exams related to diabetes and glaucoma.
Medicare Part B will cover glaucoma screenings once every 12 months for individuals who are at a high risk of developing the eye disease glaucoma. High risk patients include individuals who have diabetes, have a family history of glaucoma, are African American and age 50 or older, or are Hispanic and age 65 or older. Your screening must be done by (or supervised by) an eye doctor who’s legally allowed to perform glaucoma screenings in your state.
When receiving a glaucoma screening, you will be responsible for paying a coinsurance of 20% of the Medicare-approved amount (after meeting your deductible). If you’re in a hospital outpatient setting such as an emergency department or surgery center, you will also need to pay a copayment.
Individuals with diabetes will receive coverage for eye examinations for diabetic retinopathy once each year through Medicare Part B. If you have diabetes, it’s important to utilize your Medicare benefits to get an eye exam each year. Early detection of diabetic retinopathy can stop the damage to your eye and prevent blindness. Medicare Part B will cover 80% of the cost of the exam, leaving beneficiaries with 20% to pay out-of-pocket. Your Medicare Part B deductible does apply.
Medicare Coverage for Glasses
Medicare does not typically provide coverage for eyeglasses or contact lenses. However, there is an exception for individuals who undergo cataract surgery that involves the implant of an intraocular lens. Medicare Part B will cover one pair of eyeglasses with standard frames or one set of contact lenses after each cataract surgery that implants an intraocular lens.
Individuals who undergo cataract surgery must get their corrective lenses from a supplier enrolled in Medicare for Medicare to pay its share of the costs. Since these items are covered by Medicare Part B, you will be responsible for paying 20% of the Medicare-approved cost after meeting your Medicare Part B deductible.
If you have not had cataract surgery and are looking to get eyeglasses or contact lenses, you will be responsible for paying 100% of the cost unless you have vision coverage outside of Original Medicare.
Does Medicare Advantage Cover Vision?
Medicare Advantage plans are required to provide the same benefits as Original Medicare. Therefore, all Medicare Advantage plans must provide coverage for the services mentioned above, including an annual glaucoma screening for high-risk individuals and diabetic retinopathy tests for diabetic patients.
Medicare Advantage plans may offer additional coverage outside of what is covered by Original Medicare. Plan benefits, costs, and availability will vary by carrier and location. To check which services your Medicare Advantage plan covers, you can review the plan’s Summary of Benefits and the Evidence of Coverage.
Don’t forget that many Medicare Advantage plans provide coverage within a network of providers. If you receive services from a provider that isn’t in your network, you may need to pay all costs.
Vision Insurance Plans for Medicare Beneficiaries
For Medicare enrollees who are looking to fill in the gaps in their vision coverage, individual vision insurance plans are available. If a plan is available in your area, you can enroll in a standalone vision plan regardless of whether you have Original Medicare or a Medicare Advantage plan.
Vision plans typically offer a comprehensive range of coverage including routine eye exams, contact lens exams, eyeglasses, and more. Vision insurance can also be obtained through a Dental, Vision, and Hearing plan. Some insurance carriers bundle dental, vision, and hearing coverage together into one insurance plan. These plans can be a great option for individuals who are looking to round out their Medicare coverage, since dental, vision, and hearing coverage is limited under Original Medicare.
Keep in mind that when you enroll in a standalone vision plan, your plan will have a monthly premium. You will need to pay this premium in addition to your Medicare Part B premium. If you have a Medicare Advantage plan, you will be paying your vision plan premium, Medicare Advantage plan premium, and Medicare Part B premium each month. Consider your monthly budget when finding and comparing standalone vision plans.
Other Ways for Medicare Enrollees to Get Help with Vision Costs
As we mentioned above, early detection through preventative care is one of the best ways to protect your vision. If you are having difficulty affording vision care, there are some options available for reducing your costs.
Dual-eligible individuals who have Medicare and Medicaid may be able to get help with vision costs through Medicaid. Some state Medicaid programs will provide reimbursement for visual care services and supplies including routine refraction exams, prescription eyeglasses, prosthetic eyes, and more. Contact your state’s Medicaid office to find out which vision coverage Medicaid provides and who qualifies.
EyeCare America is a public service program that connects volunteer ophthalmologists with individuals who are unable to afford vision care. They have a Seniors Program that is open to people who are over the age of 65. Through this program, some individuals can get a medical eye exam at no cost.
If you have VA healthcare benefits, you may be able to get routine and preventative vision coverage through the VA. Some items, such as eyeglasses, may have requirements for receiving coverage. Review your VA benefits for more information or contact the VA health benefits hotline at 877-222-8387.
Still have questions regarding Medicare’s vision coverage? Our team of licensed insurance agents can help answer any questions you may have regarding your options when it comes to Medicare and eye care. Get your questions together and give us a call at the number above to speak with an agent.
Sources
Is Your Test, Item, or Service Covered? Medicare.gov. Accessed December 2023
https://www.medicare.gov/coverage/is-your-test-item-or-service-covered
Facts and Figures on Adults with Vision Loss, American Foundation for the Blind. Accessed December 2023
https://www.afb.org/research-and-initiatives/statistics/adults
Eye Conditions and Diseases, National Eye Institute. Accessed December 2023
https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases
