Does Medicare Cover Optometrist Services?
Navigate Medicare's complex rules for eye care. Discover what medical vision services are covered and how routine exams can be included.
Medicare is a federal health insurance program for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. This article clarifies what optometrist services are covered, what is excluded, and how different Medicare options approach vision benefits.
Original Medicare Coverage for Medically Necessary Optometrist Services
Original Medicare Part B (Medical Insurance) covers optometrist services deemed medically necessary for diagnosing and treating eye diseases and conditions. This applies when an eye condition impacts your health and requires medical intervention. For instance, services related to conditions like glaucoma, cataracts, diabetic retinopathy, and macular degeneration are generally covered.
Covered services may include diagnostic tests, such as visual field tests for glaucoma or optical coherence tomography for various retinal conditions, to monitor and assess the progression of these diseases. Office visits for the ongoing management and treatment of these eye illnesses or injuries are also included. Additionally, Part B may cover certain medical treatments or minor procedures performed by an optometrist within their professional scope, such as foreign body removal from the eye.
Routine Vision Care and What Original Medicare Does Not Cover
Original Medicare (Part A and Part B) generally does not cover routine eye examinations. These are annual check-ups performed solely to assess vision and determine prescriptions for eyeglasses or contact lenses. The primary purpose of such exams is to correct refractive errors, not to diagnose or treat a medical condition.
Furthermore, the cost of eyeglasses, including frames and lenses, and contact lenses is not covered by Original Medicare. This exclusion applies even if you have a prescription from a covered medical eye exam. There is one specific exception: Original Medicare Part B will cover one pair of eyeglasses or contact lenses after cataract surgery that implants an intraocular lens. Elective procedures, such as LASIK surgery, which aim to correct refractive errors, are also excluded from Original Medicare coverage.
Medicare Advantage Plans and Supplemental Vision Benefits
Medicare Advantage Plans, also known as Medicare Part C, offer an alternative way to receive Medicare benefits through private insurance companies approved by Medicare. These plans are required to provide at least the same level of benefits as Original Medicare Part A and Part B. Many Medicare Advantage plans also include additional benefits that Original Medicare does not cover.
A significant number of Medicare Advantage plans offer supplemental vision benefits, which often include coverage for routine eye care. These benefits can encompass an annual routine eye exam and frequently provide an allowance toward the cost of eyeglasses or contact lenses. The specific vision benefits, such as the frequency of covered exams, the monetary allowance for eyewear, and any network restrictions, can vary substantially among different Medicare Advantage plans and geographic regions. To access these additional vision benefits, individuals must enroll in a Medicare Advantage plan.
Managing Out-of-Pocket Costs and Accessing Care
For medically necessary optometrist services covered by Original Medicare Part B, beneficiaries are responsible for a portion of the costs. After meeting the annual Part B deductible ($257 in 2025), individuals pay 20% coinsurance of the Medicare-approved amount for most services. Medicare pays the remaining 80%.
Medicare Advantage plans have their own cost-sharing structures, which can include copayments for office visits or other services, and sometimes deductibles. These costs vary significantly by plan, so it is important for beneficiaries to review their plan’s specific details.
Before scheduling an appointment, it is always advisable to confirm with the optometrist’s office whether they accept your specific Medicare coverage, whether it is Original Medicare or a particular Medicare Advantage plan. Patients should also inquire about potential out-of-pocket costs, especially if a visit involves both medically necessary services and components that might not be fully covered, such as a refraction for eyeglasses, which may incur an extra charge.