Does Medicare Part B Cover Ophthalmologist?
Understand Medicare Part B's coverage for ophthalmologist visits, including what medical eye care is covered, its limits, and your costs.
Medicare Part B functions as medical insurance, covering various outpatient services, including some ophthalmologist visits. This coverage primarily extends to medically necessary care for eye diseases and conditions rather than routine vision check-ups. Understanding the scope of Part B’s coverage involves distinguishing between services that address medical concerns and those for general vision correction.
Medical Eye Care Coverage under Part B
Medicare Part B covers a range of diagnostic and treatment services for eye diseases and conditions when provided by an ophthalmologist. An ophthalmologist is a medical doctor (MD) or osteopathic doctor (DO) specializing in comprehensive eye and vision care, including medical and surgical treatment. This medical qualification means their services for eye conditions typically fall under Part B.
Coverage includes examinations and treatments for common eye conditions such as cataracts, glaucoma, macular degeneration, and diabetic retinopathy. For instance, if you have diabetes, Part B covers a yearly eye exam to screen for diabetic retinopathy. Similarly, for individuals at high risk of glaucoma, Part B covers one glaucoma test every 12 months. This includes people with a family history of glaucoma, those with diabetes, African Americans aged 50 or older, and Hispanic individuals aged 65 or older.
Diagnostic tests, such as visual field tests, tonometry (to measure eye pressure), and optical coherence tomography (OCT), are covered when medically necessary to diagnose or monitor eye conditions. Surgical procedures, including cataract surgery to replace a cloudy lens with an artificial one, are also covered by Medicare Part B. This coverage extends to follow-up care related to these conditions or surgeries, ensuring ongoing medical management.
When Part B Does Not Cover Eye Care
While Medicare Part B provides coverage for medically necessary eye care, it generally does not cover routine eye exams for general vision check-ups. This means that if you simply need an exam to update your eyeglasses prescription without a diagnosed medical condition, Part B will not cover the cost.
Original Medicare typically does not cover eyeglasses or contact lenses. However, there is a specific exception: Part B will pay for one set of contact lenses or standard eyeglasses frames after cataract surgery that implants an intraocular lens. Refractive surgeries, such as LASIK, are also generally not covered because they are considered elective procedures to improve vision rather than treat a medical condition.
An optometrist (OD) typically provides routine eye exams and prescribes corrective lenses, while an ophthalmologist (MD/DO) treats medical eye conditions and performs surgery. Part B’s coverage applies primarily to medically necessary services from an ophthalmologist.
Understanding Your Costs and Provider Choices
When receiving eye care covered by Medicare Part B, individuals are responsible for certain costs. The standard Medicare Part B annual deductible applies, which is $257 in 2025. After this deductible is met, you typically pay 20% of the Medicare-approved amount for covered services. This 20% is known as coinsurance. The Medicare-approved amount is the fee that Medicare agrees to pay healthcare providers for a specific service.
Choosing an ophthalmologist who “accepts Medicare assignment” can help manage out-of-pocket expenses. When a provider accepts assignment, they agree to accept the Medicare-approved amount as full payment for services. This means they cannot charge you more than the deductible and coinsurance amount, and they will submit the claim directly to Medicare.
Some individuals may have additional insurance, such as a Medicare Supplement (Medigap) policy or a Medicare Advantage (Part C) plan, which can affect their cost-sharing. Medigap plans help cover some of the out-of-pocket costs of Original Medicare, like deductibles and coinsurance. Medicare Advantage plans often offer additional benefits beyond Original Medicare, which may include routine vision care, but their costs and covered services vary by plan. It is advisable to confirm coverage details with your ophthalmologist’s office or Medicare directly before receiving services to understand potential financial responsibilities.