Anyone who has ever had to replace a lightbulb can attest that most things eventually wear out. The same is true for our eyes — but since we can’t replace them, we need to protect them.
Will Medicare cover vision care and eye exams?
While Medicare, the federal health insurance program that provides coverage for millions of Americans, does offer some vision care coverage, it’s important to understand the specifics to determine if it will be what’s needed for your particular situation.
This blog will break down vision coverage for the two primary components of Original Medicare, Parts A and B. We’ll also look at Part C, Medicare Advantage. When you’re done reading, contact us if you still have questions.
Original Medicare doesn’t always cover eye exams
Original Medicare, comprised of Part A (hospital insurance) and Part B (medical insurance), covers some vision-related services — but not all.
What does Medicare Part A cover?
Because Medicare Part A is hospital insurance, it only covers vision care when it’s a medical issue — as in a medical emergency or traumatic injury. This would include surgical treatments for glaucoma, macular degeneration, and diabetic retinopathy, which is a complication of diabetes that can cause vision loss. Also covered are certain dry eye conditions, detached retina treatments, YAG laser capsulotomy, and cataract surgery.
Medicare Part A does not cover routine eye exams for eyeglasses or contact lenses. If all you have is Medicare Part A, costs associated with exams, eyeglasses, or contacts are 100 percent the patient’s responsibility.
What does Medicare Part B cover?
Like Part A, routine eye exams for corrective eyewear are not covered by Medicare Part B — unless you need vision correction after cataract surgery. This is because Medicare Part B is preventative medical insurance. Other instances where eye exams are covered include:
- If your vision issues indicate a serious eye condition, Part B covers eye exams and some diagnostic procedures — even if it’s determined there is no medical loss of vision.
- If you’re diabetic or have an elevated risk of glaucoma, Part B covers annual eye exams.
- If you have macular degeneration, Part B covers eye exams and ocular photodynamic therapy (PDT) with verteporfin, a relatively new treatment.
Less common — but equally important — are benefits that cover eye prostheses for patients with an absence or shrinkage of the eye due to trauma, congenital disability, or necessary surgical removal.
With Medicare Part B, your co-pay is typically 20 percent of the Medicare-approved amount after you meet your deductible. In other words, you’re responsible for paying out-of-pocket before Medicare kicks in to cover the remaining vision care costs.
Good news – Medicare Advantage covers eye exams
If you need routine eye exams for vision correction, you’ll want more comprehensive coverage like that provided by Medicare Part C — also known as Medicare Advantage — a preventative vision plan offered by private insurance companies.
In fact, many Medicare Advantage plans also cover corrective eyewear, in which you either pay a flat fee or a co-pay toward purchasing prescription eyeglasses or contact lenses.
Also, if you have an eye condition requiring medication, most Medicare Advantage plans include coverage for prescription drugs and over-the-counter treatments through Medicare Part D.
How often does Medicare pay for eye exams?
Plans differ based on who provides the coverage, but the short answer is that Medicare Advantage typically covers eye exams annually. However, some cover just one eye exam every two years, and some don’t cover routine exams at all.
Also important: Medicare Advantage plans may have restrictions and payment responsibilities that differ from Original Medicare. Before enrolling, it’s essential to carefully review plan details and evaluate them against your needs and budget.
We can help
As you’ve read, Original Medicare (Parts A and B) does offer some coverage for vision care services, but it’s generally limited to surgical and preventive services and does not cover routine eye exams for glasses or contacts. For that, you should explore a Medicare Advantage or a private vision insurance plan.
Need help? Our Baldwin Group team can help you understand your vision care coverage and discuss your options.
