There are many reasons we struggle with our vision as we get older. Sometimes it’s simply a function of age, and other times there are illnesses such as diabetes and glaucoma that may cause issues.
If you use Medicare as your primary health coverage, you’re probably wondering, “Does Medicare pay for eye exams? How much is an eye test with Medicare?” The answers will depend on which Medicare plan you have, as well as the underlying conditions behind your vision issues.
Let’s take a look at Medicare vision coverage.
Original Medicare, which consists of Parts A and B, has much more limited coverage for vision issues than many Medicare Advantage plans. Medicare Advantage is offered by private insurance companies, and your options vary depending on your local area. You’ll want to check your plan specifics before you make a vision appointment.
Because diabetes is a medical condition that causes eye problems, Original Medicare does cover eye exams for diabetics. However, these exams are only designed to look for diabetic retinopathy and are covered once a year.
If you have a Medicare Advantage plan, you will also have coverage for a yearly diabetic retinopathy exam. All Advantage plans must offer at least as much coverage as Original Medicare. You may get other benefits as well.
Glaucoma can cause damage to the optic nerve due to high pressure in your eye. This is a medical condition that is important to catch early and is one of the leading causes of blindness in those over age 60.
Original Medicare does cover an annual test for glaucoma if you’re in a high-risk category for the disease.
High risk includes:
Medicare Advantage will also cover a glaucoma screening once a year if you’re in a high-risk category. You may also be covered for screening in other circumstances. You’ll want to check with your specific plan for details.
How much does Medicare pay for an eye exam? If an eye exam is covered by Original Medicare, you would have your normal Medicare Part B out-of-pocket costs. That means meeting your annual deductible if you have not done so yet, and then paying 20% of the Medicare-approved cost for the exam.
If you have a Medicare Advantage plan, you may have different costs. For example, there could be a set copayment instead of a percentage. You’ll need to review your plan’s coverage information so you know what to expect. Learn more about the latest updates to Medicare premiums and deductibles.
In general, Original Medicare pays for medically-necessary care. That means eye exams for medical issues such as diabetes, cataracts, macular degeneration, and glaucoma are likely to be covered at the normal level if they are necessary. To be considered medically necessary, you’ll need to be in a high-risk category or have signs of these conditions.
Original Medicare does not cover routine vision eye exams, glasses, or contact lenses. However, if you have a Medicare Advantage plan, you may have coverage for these routine vision needs. Many Advantage plans add vision coverage as an extra benefit. Review your plan details to ensure you’re using your coverage to its full potential.
An optometrist is a doctor that provides vision and eye care services. They often focus primarily on vision correction with eyeglasses or contact lenses, but can also perform exams for medically-related conditions like diabetic retinopathy and glaucoma.
Optometrist appointments are only covered by Original Medicare if they are related to a medically necessary condition, like an annual diabetic retinopathy exam for those with diabetes. Routine eye care for vision is not covered.
However, if you have a Medicare Advantage plan, you may have additional vision benefits. That would mean that you would receive coverage for vision exams and other routine care.
An ophthalmologist is a medical professional that treats eye conditions. While they can provide vision exams for corrective lenses, they focus more on medical eye care and surgical processes. For example, they can perform surgery to correct crossed eyes or glaucoma and diagnose and treat eye conditions related to diabetes or other health conditions.
Because an ophthalmologist is focused on medical care instead of vision correction, your appointment is more likely to be covered by Original Medicare. However, Medicare will still need to deem the procedure or exam medically necessary. That means, for example, that cosmetic eye surgery will not be covered.
Medicare Advantage plans will also cover medically-necessary care from an ophthalmologist. However, you may get additional coverage for vision correction as well. It all depends on what’s included in your Advantage plan.
This guide covered most of the common questions about Medicare coverage of eye exams, but you might have additional concerns related to your specific needs. We’re here to help. If you want to find out more about Medicare and vision coverage, or need to compare plans to find the right options for your needs, contact us today!