When Does Medicare Pay for an Eye Exam?
Understand the intricacies of Medicare's eye exam coverage. Learn when Original Medicare and Medicare Advantage plans pay for vision care.
Medicare plays a significant role in healthcare coverage for millions, supporting overall well-being, which includes maintaining good eye health. Regular eye examinations are an important component of preventive care, as they can help detect potential issues early. Understanding how Medicare covers these services can assist beneficiaries in navigating their healthcare options effectively to receive necessary eye care.
Original Medicare Coverage for Eye Exams
Original Medicare, consisting of Part A and Part B, does not cover routine eye exams for general vision correction or for prescribing eyeglasses and contact lenses. However, Medicare Part B does cover eye exams in specific medically necessary situations, including those prompted by an illness or injury affecting the eye.
Individuals diagnosed with diabetes are eligible for one annual eye exam to check for diabetic retinopathy, a condition that can damage blood vessels in the eye. This exam helps in the early detection and management of vision problems related to diabetes. The exam must be performed by an eye doctor legally permitted to conduct such tests in the beneficiary’s state.
Medicare Part B also covers annual glaucoma screenings for those considered at high risk. High-risk criteria include having diabetes, a family history of glaucoma, being African American aged 50 or older, or Hispanic aged 65 or older. For covered services under Part B, beneficiaries must first meet the annual deductible, which is $257 in 2025. After the deductible is met, Medicare pays 80% of the Medicare-approved amount, leaving the beneficiary responsible for a 20% coinsurance.
Medicare Advantage Plans and Eye Exams
Medicare Advantage Plans, also known as Medicare Part C, are health plan options offered by private companies approved by Medicare. These plans are required to cover at least all the benefits that Original Medicare provides, including the same medically necessary eye exams.
Many Medicare Advantage plans include additional benefits that Original Medicare does not cover. These extra benefits include coverage for routine eye exams and allowances for eyeglasses or contact lenses. The specific scope of routine vision coverage, such as exam frequency or eyewear allowance, can vary considerably between different Medicare Advantage plans.
Beneficiaries considering a Medicare Advantage plan should carefully review the plan’s specific benefits package. This review helps determine the extent of routine vision coverage available, including any limits on services or eyewear allowances, to choose a plan that aligns with individual vision care needs.
Coverage for Specific Eye Conditions and Treatments
Beyond eye exams, Medicare also provides coverage for a range of specific eye conditions and their treatments. For instance, medically necessary surgical procedures, such as cataract surgery, are covered under Medicare Part B. This coverage includes the removal of the cataract and the implantation of a standard intraocular lens.
Following cataract surgery that involves an intraocular lens implant, Medicare Part B covers one pair of corrective eyeglasses with standard frames or one set of contact lenses. This benefit helps address vision changes after the procedure. Diagnostic tests for identifying and monitoring eye diseases, such as optical coherence tomography for macular degeneration or visual field tests for glaucoma, are also covered.
Medicare Part B also covers durable medical equipment related to eye care, such as prosthetic eyes. These devices are covered when medically necessary, with a replacement period of five years, provided a doctor certifies the need.