How Often Does Medicare Pay for Eye Exams?

Medicare is a federal health insurance program for individuals aged 65 or older, younger people with certain disabilities, and those with End-Stage Renal Disease. Understanding its coverage for eye care can be complex, as it varies based on the type of service and the specific Medicare plan. Routine eye exams, such as those for prescribing eyeglasses or contact lenses, are generally not covered by Original Medicare. However, specific eye conditions and medically necessary treatments may receive coverage.

Original Medicare Coverage for Eye Care

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), distinguishes between routine vision care and medically necessary eye care.

Medicare Part B provides coverage for eye exams and treatments deemed medically necessary due to an illness, injury, or specific medical condition. This includes diagnostic tests and treatments for various eye diseases.

Coverage under Part B also extends to services such as surgical procedures designed to restore eye function impaired by chronic conditions. Part A plays a very limited role in eye care, primarily covering inpatient hospital stays related to eye injuries or surgeries. The frequency of these medically necessary services is determined by a doctor based on medical need.

Specific Eye Conditions and Covered Exams

Medicare Part B offers specific coverage for eye exams related to several common eye conditions, often with defined frequencies. For individuals at high risk of glaucoma, Medicare Part B covers a yearly screening. 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 surgery, including the insertion of an intraocular lens, is covered by Medicare Part B when medically necessary. This coverage extends to pre-operative exams, the removal of the cataract, lens implantation, and post-operative exams. Medicare generally covers basic intraocular lens implants, but not more advanced options.

For age-related macular degeneration (AMD), Medicare Part B covers diagnostic tests and treatments, such as injections. These services are covered as often as medically necessary for individuals diagnosed with AMD.

Individuals with diabetes receive coverage for an annual eye exam to check for diabetic retinopathy. This yearly exam helps detect damage to blood vessels at the back of the eye, which can lead to vision loss. Other medically necessary conditions, such as a detached retina or the presence of foreign objects in the eye, also receive coverage under Medicare Part B for diagnosis and treatment.

Medicare Advantage and Routine Vision Benefits

Medicare Advantage plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans are required to provide all the benefits covered by Original Medicare (Parts A and B). Many Medicare Advantage plans offer additional benefits that Original Medicare does not cover, including routine eye exams, eyeglasses, and contact lenses.

The specific coverage for routine eye exams, such as an annual exam, and the allowances for eyewear can vary significantly among different Medicare Advantage plans. Some plans may offer a yearly routine eye exam and a specific allowance for glasses or contacts. Beneficiaries should review the details of their chosen plan to understand the extent of vision coverage and any associated costs or provider networks.

These plans may also have specific networks of vision providers that beneficiaries must use to receive covered services at the lowest cost. While Medicare Advantage plans can offer more comprehensive vision benefits, it is important to compare plans carefully as benefits and costs differ.

Out-of-Pocket Expenses and Non-Covered Items

Even for eye care services covered by Original Medicare, beneficiaries incur out-of-pocket expenses. After meeting the annual Part B deductible, which is $257 in 2025, individuals are generally responsible for a 20% coinsurance of the Medicare-approved amount. This applies to physician services and outpatient care.

Original Medicare generally does not cover routine eye exams, eyeglasses, or contact lenses, considering them non-medically necessary. However, there is a notable exception: Medicare Part B covers one pair of standard prescription eyeglasses or contact lenses after cataract surgery that includes the insertion of an intraocular lens. This coverage applies to basic frames and standard lenses, not upgrades or specialty lenses.

Beneficiaries should always confirm coverage and potential costs with their doctor’s office and their Medicare plan before receiving services. Medigap policies, or Medicare Supplement Insurance, can help cover some of the out-of-pocket costs associated with services covered by Original Medicare, such as the Part B coinsurance and deductibles. However, Medigap plans do not add new benefits like routine vision care that Original Medicare does not cover.