Does Medicare Part A and B Cover Eye Exams?

This article clarifies what Original Medicare (Parts A and B) covers regarding eye exams and related vision care. It also explores additional avenues for obtaining broader vision coverage.

Medicare Part A and Eye Exams

Medicare Part A primarily covers inpatient hospital care. Routine eye exams, eyeglasses, or contact lenses are not covered under Part A.

Eye care may be covered only if it is an integral part of a medically necessary inpatient hospital stay. For instance, if eye surgery necessitates an overnight hospital admission, associated facility costs might fall under Part A. This coverage does not extend to routine vision check-ups or corrective eyewear.

Medicare Part B and Eye Exams

Medicare Part B covers medically necessary outpatient services, including doctor visits and preventive services. Routine eye exams for prescribing glasses or contact lenses are generally not covered. However, Part B does provide coverage for specific eye-related services when medically necessary.

For individuals with diabetes, Medicare Part B covers one annual eye exam to check for diabetic retinopathy. This condition involves damage to the blood vessels in the eye, which can lead to vision problems. The exam must be performed by an eye doctor legally permitted to conduct such tests in your state.

Glaucoma screenings are covered once every 12 months for individuals identified as high-risk. This includes those with diabetes, a family history of glaucoma, African Americans aged 50 or older, and Hispanic Americans aged 65 or older. The screening typically involves a dilated eye examination, intraocular pressure measurement, and an ophthalmoscopy or slit-lamp biomicroscopic examination.

Medicare Part B covers cataract surgery, which includes the removal of the cataract and the insertion of a standard intraocular lens. This coverage extends to pre-operative and post-operative exams related to the surgery. After cataract surgery, Part B also covers one pair of eyeglasses with standard frames or one set of contact lenses. However, advanced or premium intraocular lenses and upgraded eyeglass frames are typically not covered, requiring out-of-pocket payment for the difference.

Part B covers diagnostic tests and treatment for other eye diseases and conditions, such as age-related macular degeneration (AMD). This includes certain injections and therapies for AMD, provided they are medically necessary. After meeting the annual Part B deductible, beneficiaries are generally responsible for 20% of the Medicare-approved amount for these services.

Other Medicare Coverage for Eye Care

Since Original Medicare (Parts A and B) has limitations regarding routine eye exam coverage, beneficiaries have alternative options to obtain broader vision care. These options are typically offered through private insurance companies.

Many Medicare Part C, or Medicare Advantage Plans, often include additional benefits not covered by Original Medicare, such as routine vision care. These plans may cover annual eye exams, eyeglasses, and sometimes contact lenses. Benefits and costs vary significantly among plans, so reviewing specific plan details is advisable.

Medicare Supplement Insurance (Medigap) helps cover out-of-pocket costs like deductibles, copayments, and coinsurance for services already covered by Original Medicare. Medigap policies do not add new benefits, meaning they will not cover routine eye exams if Original Medicare does not.

Some individuals may choose to purchase separate, stand-alone vision insurance plans from private companies. These plans are designed specifically to cover routine eye care, including exams and corrective lenses, providing comprehensive coverage beyond what Original Medicare offers. This can be a suitable option for those who want predictable costs for routine vision needs.