Does Medicare Cover Ophthalmology Services?

Medicare is a federal health insurance program designed primarily for individuals aged 65 or older. The program also extends coverage to certain younger people with disabilities and those with End-Stage Renal Disease. Eye health concerns become more prevalent with age, making understanding Medicare’s role in vision care important for many.

Medicare’s coverage for eye care services is not all-encompassing. It specifically addresses medical conditions affecting the eyes rather than routine vision needs. The program aims to cover treatments and diagnoses for diseases that can impact vision, rather than general eye examinations for corrective lenses.

Medicare Part B Coverage for Eye Health

Medicare Part B, which serves as medical insurance, covers a range of medically necessary services and supplies, including certain outpatient eye care. This coverage is specifically for medical conditions and treatments, not routine vision services.

Cataract surgery is one of the primary ophthalmology services covered by Medicare Part B. This includes the surgical procedure itself, facility fees, professional fees for the ophthalmologist, and the cost of basic intraocular lenses implanted during the surgery. Following cataract surgery with an intraocular lens, Medicare Part B also covers one pair of eyeglasses or contact lenses.

Diagnosis and treatment of glaucoma are also covered under Part B. This includes eye examinations if an individual is at high risk for glaucoma, along with specific diagnostic tests and treatments such as prescription eye drops or laser surgery. Similarly, medically necessary services for macular degeneration, including certain diagnostic tests like optical coherence tomography (OCT) and treatments like anti-VEGF injections, fall under Part B coverage.

Individuals with diabetes can receive coverage for eye exams to check for diabetic retinopathy, as well as treatment if the condition is present. Medicare Part B also covers other medical eye conditions that require intervention, such as eye infections, injuries, or diseases directly affecting the eye. All these services must be performed by an ophthalmologist or another eye care professional who accepts Medicare assignment.

Medicare Advantage Plans and Eye Care

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies that have contracts with Medicare. These plans are required by law to provide at least the same coverage as Original Medicare, which includes all the medically necessary ophthalmology services covered under Medicare Part B.

Many Medicare Advantage Plans offer additional benefits beyond what Original Medicare provides, which often include routine eye exams. These plans may also provide allowances for eyeglasses or contact lenses, addressing vision needs that Original Medicare generally does not cover. The scope of these additional benefits varies significantly among plans.

The coverage details and associated costs, such as deductibles, copayments, and coinsurance, can differ substantially between Medicare Advantage plans, even within the same geographic area. Individuals should review the plan’s Summary of Benefits to understand routine eye care coverage. Some plans may require beneficiaries to use providers within a specific network for routine vision services.

Services Not Covered by Original Medicare

Original Medicare generally does not cover routine eye exams. This includes examinations performed solely for the purpose of prescribing eyeglasses or contact lenses, or for general vision screening without a specific medical diagnosis. These types of services are typically considered elective or preventative rather than medically necessary treatments for disease or injury.

The cost of eyeglasses or contact lenses is also typically not covered by Original Medicare. There is a specific exception for one pair of eyeglasses or contact lenses provided after cataract surgery that involves the implantation of an intraocular lens. Beyond this particular circumstance, expenses for corrective eyewear are usually the responsibility of the beneficiary. Cosmetic eye surgery, performed solely to enhance appearance rather than to correct a medical condition resulting from injury or disease, is another service not covered by Original Medicare.

Costs and Accessing Covered Eye Care

For most ophthalmology services covered under Original Medicare Part B, beneficiaries are responsible for certain costs. After meeting the annual Part B deductible, Medicare typically pays 80% of the Medicare-approved amount for the service. The beneficiary is then responsible for the remaining 20% coinsurance. In 2025, the annual Part B deductible is $257.

Original Medicare does not have an annual limit on out-of-pocket costs. Individuals can consider purchasing a Medigap (Medicare Supplement Insurance) policy to help cover these out-of-pocket expenses, such as the Part B deductible and coinsurance amounts. Medigap plans help pay some of the costs that Original Medicare does not cover.

Medicare Advantage Plans have varying cost structures for covered ophthalmology services. These plans may include different deductibles, copayments, or coinsurance amounts depending on the specific plan chosen. A significant difference with Medicare Advantage Plans is that they include an annual out-of-pocket maximum. Once this maximum is reached, the plan typically pays 100% of covered services for the remainder of the year.

Accessing covered eye care under Original Medicare generally does not require a referral to see an ophthalmologist, provided the ophthalmologist accepts Medicare assignment. For Medicare Advantage Plans, however, some plans, particularly Health Maintenance Organization (HMO) plans, may require a referral from a primary care provider before seeing a specialist. Beneficiaries can use Medicare’s “Physician Compare” tool or directly contact the ophthalmologist’s office to confirm they accept Medicare.

For those with a Medicare Advantage Plan, checking the plan’s provider directory is essential to ensure the ophthalmologist is in-network. Some services, especially certain procedures or specialized diagnostic tests, may require prior authorization from Medicare or the Medicare Advantage Plan before they are performed. In most cases, the healthcare provider’s office will submit claims directly to Medicare or the Medicare Advantage Plan on behalf of the beneficiary.