Does Medicare Pay for an Eye Exam Once a Year?

Medicare, a federal health insurance program, provides coverage for millions of Americans, primarily those aged 65 or older, and some younger individuals with disabilities. Understanding what services are covered can be complex. Knowing your plan’s specifics is important for managing healthcare expenses and accessing necessary medical care, including vision services.

Original Medicare and Routine Eye Care

Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), generally does not cover routine eye exams, eyeglasses, or contact lenses. These services are considered “routine” when their primary purpose is to check vision or prescribe corrective lenses, not to diagnose or treat a medical condition. For example, an annual visit solely to update a glasses prescription falls outside coverage. Beneficiaries are usually responsible for the full cost of such routine vision care.

Medically Necessary Eye Care Coverage

Medicare Part B covers certain eye care services when medically necessary to diagnose or treat an eye disease or condition. This includes exams performed due to symptoms of an underlying medical issue or as part of treatment for an existing eye condition. For instance, Medicare Part B covers glaucoma tests for individuals at high risk, such as those with diabetes, a family history of glaucoma, or African Americans aged 50 and older.

Coverage also extends to diagnostic tests and treatments for various eye diseases. For example, services related to diabetic retinopathy, age-related macular degeneration, or cataracts are typically covered. If you need cataract surgery, Medicare Part B helps pay for the surgery, including cataract removal and intraocular lens insertion. The program also covers related services and supplies, such as facility fees and anesthesia.

Medicare Advantage and Prescription Drug Coverage for Eye Care

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans provide all the benefits of Original Medicare and often include additional benefits not covered by Original Medicare, such as routine vision care. Many Medicare Advantage plans offer coverage for annual routine eye exams, and some may even provide allowances for eyeglasses or contact lenses. Specific vision benefits and their associated costs can vary between different Medicare Advantage plans.

Beneficiaries should review the plan’s Evidence of Coverage document to understand the scope of vision benefits, including any limitations or copayments. In addition to vision care, Medicare Part D plans, which provide prescription drug coverage, can help cover the cost of prescription eye medications. This includes drugs for conditions like glaucoma, severe dry eye, or infections, making pharmaceutical treatments for eye health more affordable. The specific drugs covered and their costs depend on the individual Part D plan’s formulary.

Understanding Your Costs and Finding Providers

For medically necessary eye care services covered by Medicare Part B, beneficiaries typically pay a Part B deductible. In 2025, the annual Part B deductible is $240. After the deductible is met, Medicare generally pays 80% of the Medicare-approved amount for most doctor’s services, and you are responsible for 20% coinsurance. For example, if a covered eye exam costs $100 and you’ve met your deductible, Medicare would pay $80, and you would pay $20.

Medicare Advantage plans have different cost-sharing structures, including copayments, deductibles, and coinsurance for both routine and medically necessary services. These costs can vary based on the specific plan and service received. To minimize out-of-pocket expenses, choose eye care professionals who accept Medicare assignment. Providers who accept assignment agree to accept the Medicare-approved amount as full payment for covered services, ensuring you pay only the deductible and coinsurance. You can typically find a list of participating providers through your Medicare plan’s website or by contacting their customer service.