No, Original Medicare will not pay for routine eye exams that test a beneficiary’s vision for glasses or contact lenses. Occasionally, however, Medicare does cover eye exams prescribed by a doctor as medically necessary for diagnosing or managing a chronic medical condition.
Approved evaluations usually check for the following disorders:
- Diabetic retinopathy
- Age-related macular degeneration
- Retinal detachment
Notably, many Medicare Advantage Plans offered by private insurers include expanded vision, dental, and hearing benefits for little additional cost. Likewise, all Medigap policies can help absorb some or all of the standard out-of-pocket expenses associated with a covered eye exam.
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Limitations of How Medicare Coverage of Eye Exams Works
The extent and limitations of your Medicare coverage for eye exams ultimately depend on your plan details and medical eligibility.
Original Medicare will not pay for routine eye exams to determine lens prescription. In most cases, only seniors who need an evaluation to diagnose and plan treatment for a more significant medical condition can access Medicare vision benefits. Beneficiaries with diseases such as diabetes or a family history of eye issues will also have a higher chance of receiving covered care.
Cataracts occur when eye proteins break down and cause your natural lenses to become cloudy, often requiring surgical removal and replacement with an artificial lens. While Medicare may not cover routine cataract evaluations, it will help pay for medically necessary exams that help doctors diagnose the condition and prepare for cataract surgery.
Diabetic retinopathy affects blood vessels in the retinas of diabetes patients, typically leading to vision loss and blindness. While no cure exists, regular eye exams play a crucial role in the early detection and management of this degenerative condition. Therefore, if you have diabetes, Medicare might help pay for annual retinopathy exams for the rest of your life.
Glaucoma develops when the eye’s optic nerve becomes damaged from fluid buildup or internal pressure, eventually leading to blindness. While doctors cannot reverse vision loss, early detection of glaucoma can help them prevent future deterioration through eye drops, laser treatment, or surgery. Medicare will pay for medically necessary eye exams that monitor and diagnose glaucoma in people with a family history of the disease or notably high eye pressure readings.
Age-related macular degeneration (AMD) stems from natural retina deterioration or leaky blood vessels in the eye, causing a severe loss of central vision. While there is no effective treatment, special dietary supplements and surgical procedures can help slow the progress of AMD.
Medicare will occasionally pay for eye exams necessary to monitor and diagnose AMD, especially in susceptible patients who smoke cigarettes, have high blood pressure, or carry a family history of the disease.
How Medicare Advantage Covers Eyes Exams
Because private companies fund and structure their Medicare Advantage Plans independently, no definitive template exists for when and how individual plans cover vision services. However, all Medicare Advantage companies must legally offer equivalent benefits to Original Medicare, meaning policyholders would at least have medically necessary coverage for exams related to the above diseases.
Furthermore, most Medicare Advantage plans include additional protections atypical of Original Medicare, such as gym memberships, prescription coverage, and dental or vision care. In fact, 99% of Medicare Advantage members in 2021 had policies that included vision benefits. Usually, these plans cover exams and prescription eyewear up to a predetermined annual limit.
How Medigap Covers Eye Exams
While Medigap specifically helps absorb out-of-pocket Original Medicare expenses like copayments and deductibles, some private companies allow members to purchase additional protections. These optional benefits packages occasionally include reimbursement for vision exams, eyeglasses, and contact lenses below an annual expense threshold.
Furthermore, all 10 Medigap plan types at least partially reimburse the Part B coinsurance for medically necessary eye exams prescribed by a primary care physician. However, only Original Medicare members can purchase Medigap. Beneficiaries who wait more than 6 months to secure coverage after first becoming eligible may have to pay higher premiums and will have fewer plans to choose from.
How Much Do Eye Exams Cost With Medicare?
Your share of eye exam expenses will vary depending on your medical condition and whether you have coverage through Original Medicare, Medicare Advantage, or Medigap.
Original Medicare Part B will pay 80% of the Medicare-approved amount for any eye exam prescribed by a primary care doctor as medically necessary in diagnosing or managing a condition like glaucoma, cataracts, or AMD. Patients must pay the remaining 20% coinsurance and annual $240 Part B deductible entirely out of pocket.
While prices vary, most Medicare Advantage Plans cover all costs associated with an eye exam and withhold coinsurance until vision spending exceeds a fixed annual limit. Patients who surpass their yearly allotment of care must usually pay for 100% of continued services out of pocket. Medicare Advantage vision benefits cap averaged $160 per plan.
8 of the 10 primary Medigap plans cover 100% of any Part B coinsurance triggered from a medically necessary eye exam. Meanwhile, Medigap Plan K will still cover 50% of your Part B coinsurance, and Plan L will cover 75%. If you have a specialized Medigap policy with supplementary vision benefits, your share of costs will vary depending on your particular insurer.
How To Find Coverage For Eye Exams
If your Medicare plan does not cover routine eye exams, you can still secure benefits through a private insurance company, Medicare Savings Program, or Medicaid.
Standalone Vision Plans
Many private companies sell standalone plans that explicitly pay for routine eye exams, eyewear, and other related services. While prices vary depending on age, location, and contract details, average vision coverage can cost as little as $13 monthly. However, because “limited-benefit” insurance policies do not have to abide by ACA regulations, vision insurers can deny coverage or raise rates for people with pre-existing conditions.
Medicare Savings Programs
Medicare beneficiaries with limited resources can often enroll in a state-sponsored Medicare Savings Program (MSP) to help reduce the financial impact of out-of-pocket healthcare expenses. All but one MSP would fully cover the Part B coinsurance and deductible levied from a medically necessary eye exam. After securing coverage directly from their state, eligible individuals pay nothing extra for MSP benefits.
Medicaid is a federally-funded, state-operated health insurance program that provides free or low-cost benefits to people below specified income thresholds, children, disabled individuals, seniors, and pregnant women. While Medicaid eligibility depends on your state’s specific guidelines, it typically covers people below 138% of the federal poverty level.
Many states require Medicaid insurers to include vision coverage. Associated plans typically reimburse eye exams for beneficiaries over 21 years old.
Local and Community Resources
Though access and costs vary by location, uninsured individuals can still secure routine eyecare through local stores and community outreach programs. For example, major retailers like Walmart and Costco often employ professional optometrists to perform eye exams and sell prescription lenses at discounted prices. Likewise, some cities host organizations that provide free vision evaluations to seniors, disabled individuals, and low-income neighborhood residents.
Putting It All Together
Original Medicare does not cover routine eye exams. However, it will often help pay for medically necessary evaluations and diagnosis of chronic conditions like glaucoma, cataracts, diabetic retinopathy, and AMD. If you have Medigap, your policy will absorb some or all of your Part B coinsurance and deductible. Meanwhile, most Medicare Advantage plans provide baseline vision benefits for little to no extra cost.
While not everyone will experience the same symptoms, vision generally deteriorates with age. Before scheduling an eye exam, see if your primary care physician will prescribe one as medically necessary. Regardless of their diagnosis, call 1-800-MEDICARE or your specific Medicare Advantage insurer to guarantee a thorough understanding of your vision benefits and affiliated costs.