Does Medicare Pay for an Eye Exam?

Medicare, a federal health insurance program, provides coverage for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease (ESRD). Maintaining eye health is important as vision changes can significantly impact daily life. Understanding Medicare’s eye care coverage is a common concern for beneficiaries.

Understanding Original Medicare’s Eye Exam Coverage

Original Medicare, which consists of Part A (Hospital Insurance) and Part B (Medical Insurance), generally does not cover routine eye exams. This means eye examinations for checking vision or prescribing eyeglasses or contact lenses are not included. Part A primarily covers inpatient hospital stays, and Part B covers doctor’s services, outpatient care, medical supplies, and preventive services. Routine eye care, focused on vision correction rather than medical treatment, falls outside Part B’s “medically necessary” criteria. Beneficiaries are responsible for 100% of the costs for routine eye exams, eyeglasses, or contact lenses. A simple vision test, however, is included as part of the “Welcome to Medicare” preventive visit, a one-time benefit available within the first 12 months of enrolling in Part B.

Specific Eye Conditions and Services Covered by Original Medicare

While routine eye exams are not covered, Original Medicare Part B covers eye care services when medically necessary to diagnose or treat specific eye conditions or diseases. For instance, Medicare Part B covers certain diagnostic tests and treatments for age-related macular degeneration (AMD), a condition that can lead to central vision loss. Covered services for AMD may include eye injections and other treatments.

For individuals with diabetes, Medicare Part B covers an annual eye exam to check for diabetic retinopathy, a serious eye condition that can cause vision loss. Medicare Part B also covers glaucoma screenings every 12 months for individuals considered at high risk. High-risk factors include having diabetes, a family history of glaucoma, being African American aged 50 or older, or Hispanic American aged 65 or older.

Cataract treatment is another area where Original Medicare provides coverage. Medicare Part B covers cataract surgery, including the removal of the cataract and the implantation of a standard intraocular lens (IOL), when deemed medically necessary. Following cataract surgery, Medicare Part B also helps cover the cost of one pair of eyeglasses with standard frames or one set of contact lenses. This coverage extends to exams and treatments for other medical conditions affecting the eye, such as infections or injuries.

Medicare Advantage and Eye Care Benefits

Medicare Advantage plans, also known as Medicare Part C, are offered by private companies approved by Medicare. These plans are required to cover all the services that Original Medicare (Part A and Part B) covers. However, many Medicare Advantage plans also offer additional benefits that Original Medicare does not, including routine eye care.

These additional benefits often include coverage for routine eye exams and an allowance for eyeglasses or contact lenses. The specific vision benefits, including the frequency of covered exams and the allowance for eyewear, can vary significantly from one Medicare Advantage plan to another. Beneficiaries should carefully review the specific plan details to understand the extent of their eye care coverage. Choosing a Medicare Advantage plan can be a way for individuals to obtain routine vision services that are not covered by Original Medicare.

Out-of-Pocket Costs for Eye Care

Even when eye care services are covered by Medicare, beneficiaries incur out-of-pocket costs. For services covered under Original Medicare Part B, individuals must first meet the annual Part B deductible. In 2025, the annual deductible for Medicare Part B is $257. After the deductible is met, beneficiaries are responsible for 20% of the Medicare-approved amount for the covered service, which is known as coinsurance.

For example, if a medically necessary eye exam costs $100 and the deductible has been met, Medicare would pay $80, and the beneficiary would pay $20. For Medicare Advantage plans, out-of-pocket costs can include copayments, coinsurance, and deductibles that vary by plan. Services not covered by Medicare, such as routine eye exams under Original Medicare, would be 100% out-of-pocket for the beneficiary unless they have other insurance or discount programs.

Alternative Options for Eye Care Coverage

For individuals whose Medicare coverage does not meet all their routine eye care needs, several alternative options exist to help manage costs.

• Medicaid, a joint federal and state program, often provides comprehensive eye exam coverage and eyewear for eligible individuals. Specific benefits for adults can vary by state.
• Private vision insurance plans are available for purchase directly from insurers. These plans cover routine eye exams and offer allowances or discounts on prescription eyeglasses and contact lenses.
• Vision discount programs or cards can provide reduced rates on eye exams and eyewear without being a full insurance policy.
• Community health centers and non-profit organizations often offer low-cost or free eye care services to underserved populations.
• Some individuals may have access to eye care benefits through current or former employment, or through union benefits, which can supplement Medicare coverage.