Does Medicare Cover Retinal Eye Exams?

Medicare provides coverage for various medical services for eligible individuals. It operates under specific guidelines regarding which eye care services are included. Understanding these rules is important for beneficiaries seeking eye examinations.

Understanding Medicare Coverage for Eye Exams

Medicare differentiates between routine eye exams and those considered medically necessary. Original Medicare (Parts A and B) generally does not cover routine eye exams or refractions for eyeglasses or contact lenses. A basic vision test is included in the “Welcome to Medicare” preventive visit, offered within the first year of enrolling in Part B.

Medicare Part B covers eye exams deemed medically necessary due to a specific eye condition, injury, or systemic disease. This distinction is important, as coverage is tied to a medical diagnosis rather than a general vision check. Medicare Advantage plans (Part C) are offered by private companies and must cover at least what Original Medicare covers. Many Medicare Advantage plans also offer additional benefits, such as routine vision care, eyeglasses, or contact lenses.

Covered Retinal Exams for Specific Conditions

Retinal eye exams are covered by Medicare when medically necessary to diagnose or monitor specific eye conditions. One common condition is diabetic retinopathy, which develops when high blood sugar damages retinal blood vessels. Medicare Part B covers an annual eye exam for diabetic retinopathy for individuals with diabetes.

Glaucoma, a condition involving optic nerve damage, is another area where Medicare covers retinal exams. Medicare Part B covers a glaucoma test once every 12 months for individuals at high risk, including those with diabetes, a family history of glaucoma, African Americans aged 50 or older, and Hispanic individuals aged 65 or older. Age-related macular degeneration (AMD), which affects central vision, also qualifies for Medicare coverage for diagnostic tests and treatments. Medicare Part B may cover tests for AMD, such as fluorescein angiography and optical coherence tomography (OCT) scans, to diagnose and monitor disease progression.

For medically necessary conditions, specific retinal imaging tests are covered. Optical Coherence Tomography (OCT) uses light waves to take cross-section pictures of the retina. Fundus photography captures detailed images of the retina, optic disc, and macula. Fluorescein angiography involves injecting a dye to highlight blood vessels in the retina. These tests are covered when a doctor determines them to be medically necessary.

Costs and How Coverage Works

When Medicare Part B covers a retinal eye exam, beneficiaries are responsible for out-of-pocket costs. After meeting the annual Medicare Part B deductible ($257 in 2025), individuals typically pay 20% of the Medicare-approved amount for doctor’s services and outpatient care. If the exam occurs in a hospital outpatient setting, an additional copayment may apply.

Medicare Advantage plans (Part C) have different cost-sharing structures, which may include fixed copayments for specialist visits. It is important to confirm with the specific Medicare Advantage plan about their cost-sharing for retinal exams. A doctor’s order or referral is generally required for medically necessary exams to be covered.

Ensuring the healthcare provider accepts Medicare assignment is important. A provider who accepts assignment agrees to accept the Medicare-approved amount as full payment for a service. If a provider does not accept assignment, they may charge up to 15% more than the Medicare-approved amount, known as an “excess charge,” which the beneficiary is responsible for. Most providers who bill Medicare are participating providers, meaning they accept assignment on all Medicare claims.