Does Medicare Cover Routine Eye Exams?

Medicare, a federal health insurance program, provides coverage for millions. As people age, eye health often becomes a concern, leading many beneficiaries to question their vision care coverage. Understanding Medicare’s eye care coverage is important for health and financial planning.

Original Medicare Vision Coverage

Original Medicare, composed of Part A (Hospital Insurance) and Part B (Medical Insurance), does not cover routine eye exams. This includes examinations for prescribing eyeglasses or contact lenses. Individuals are responsible for the full cost of these routine services and associated eyewear.

Part A covers inpatient hospital care; eye care is included only if part of a covered inpatient stay, not for routine vision services. Part B also excludes routine eye refractions for glasses or contact lenses. This exclusion also applies to new glasses or contacts needed for prescription changes, with one exception. Medicare Part B covers one pair of eyeglasses with standard frames or one set of contact lenses following cataract surgery that implants an intraocular lens.

Medically Necessary Eye Care

While routine vision care is not covered, Medicare Part B provides coverage for medically necessary eye care services to treat an illness or injury. This includes diagnostic tests and treatments for various eye diseases. For example, Medicare Part B covers tests and treatments for age-related macular degeneration (AMD).

Individuals with diabetes are eligible for an annual eye exam to check for diabetic retinopathy, a condition that can cause vision loss. Medicare Part B also covers glaucoma screening tests once every 12 months for individuals at high risk, such as those with diabetes, a family history of glaucoma, or certain demographic criteria. For these medically necessary services, beneficiaries pay 20% of the Medicare-approved amount after meeting the Part B deductible.

Cataract surgery is another area of coverage under Medicare Part B when medically necessary. This includes the surgical procedure to remove cataracts and implant intraocular lenses, along with pre-operative and post-operative exams. If the surgery requires an inpatient hospital stay, Medicare Part A provides coverage.

Medicare Advantage Vision Benefits

Many Medicare beneficiaries find broader vision coverage through Medicare Advantage plans, also known as Medicare Part C. These plans are offered by private insurance companies approved by Medicare and must cover all benefits of Original Medicare. A key feature of Medicare Advantage plans is their ability to offer additional benefits not covered by Original Medicare, often including routine vision care.

Many Medicare Advantage plans include coverage for routine eye exams, and some also provide allowances for eyeglasses or contact lenses. The specific vision benefits, such as exam frequency, eyewear allowance, and network restrictions, vary significantly among different plans. Beneficiaries should review plan details to understand the vision benefits available in their area.