Original Medicare covers ophthalmology in certain situations when deemed medically necessary by your doctor. Original Medicare (Part A and B) covers vision services that treat medical conditions that affect the eyes. It does not cover routine eye care, such as eye exams for contacts or glasses. Medicare Advantage Plans (Part C) often offers additional coverage for vision services.
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Understanding Ophthalmology
Ophthalmology is the branch of medicine dealing with the eye and its diseases. You may see an ophthalmologist to treat glaucoma, macular degeneration, or cataracts, to name a few. The National Eye Institute estimates that 38.7 million people will be affected by cataracts by 2030, so diagnostic eye care will continue to be a necessity for many.
An ophthalmologist is not to be confused with an optometrist, who can conduct routine screenings to fit a patient for eyeglasses or contacts or, in limited capacities, diagnose and treat eye conditions. Typically, an ophthalmologist can help with more serious eye conditions and perform surgeries and other medical treatments for severe eye disorders.
How Original Medicare Covers Ophthalmology
Original Medicare consists of two parts: Part A Hospital coverage and Part B Medical coverage. Medicare Part A will cover medically necessary eye care performed while you are an inpatient in the hospital, for example emergency eye surgery following an accident. Most Medicare-approved vision services — like screenings, treatments, and outpatient surgeries — are covered under Medicare Part B.
Medicare Part B will cover the following services:
- Cataract surgery
- Diabetic eye exams, or diabetic retinopathy
- Glaucoma screenings
- Macular degeneration exams and treatment
Once you have met your Part B deductible, Medicare will cover 80% of the total cost, and you will pay the remaining 20%.
Cataract Surgery
Cataract surgery is one of the most common procedures performed by an ophthalmologist. When someone has cataracts, it causes their eye lens to become cloudy. With cataract surgery, that lens is removed and replaced with an artificial lens. This surgery is typically performed on an outpatient basis so the patient can return home afterward.
Cataract Surgery Eligibility
Original Medicare will cover cataract surgery using the implantation of a basic intraocular lens if it is performed using traditional surgical techniques or lasers and deemed “medically necessary.” Original Medicare will also pay for one pair of eyeglasses with standard frames or one set of contact lenses post-cataract surgery, and you must purchase from a Medicare-approved supplier.
Keep these things in mind before you schedule your cataract surgery:
- Consult an ophthalmologist to ensure your cataract surgery is medically necessary.
- Keep in mind Medicare will only cover a basic intraocular lens implanted using traditional techniques or lasers.
- Be sure to use a Medicare-approved supplier for your post-surgery eyewear.
- Know the limitations of what Medicare will cover to avoid surprises.
Diabetic Eye Exams, or Diabetic Retinopathy
If you suffer from diabetes, you may be at higher risk for developing diabetic retinopathy, which is damage to the blood vessels in the retina. This can cause blurriness and even blindness in some cases.
Medicare Part B will cover one diabetic eye exam each year if you have diabetes as long as you see a doctor who is lawfully allowed to perform the test in your state. You will be subject to the standard cost-sharing under Part B.
Glaucoma Screenings
Another common eye disease is glaucoma, which is damage to the optic nerve that can lead to vision loss. Medicare will cover one glaucoma screening every 12 months if you are at high risk of developing this disease. You will pay a 20% coinsurance after you have met your Part B deductible for this service.
You may be at high risk for glaucoma if any of the following applies to you:
- Glaucoma runs in your family.
- You have diabetes.
- You are African American or Hispanic and at least age 50 or older.
Macular Degeneration Exams and Treatment
Macular degeneration happens when part of your retina, called the macula, is damaged. Age-related macular degeneration is a leading cause of vision loss for people 50 and older, according to the American Academy of Ophthalmology.
Medicare will cover certain diagnostic tests, procedures, and treatments if you have age-related macular degeneration. You will pay a 20% coinsurance after your Part B deductible is met, plus an additional facility copay if you receive care in an outpatient hospital setting.
How Does Medicare Advantage Cover Ophthalmology?
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare (Parts A and B) that is offered by private insurance companies approved by Medicare. These plans cover all the services that Original Medicare covers and often include additional benefits.
Medicare Advantage Plans usually provide more comprehensive coverage for ophthalmology compared to Original Medicare. This often includes routine eye exams, vision correction aids like glasses or contact lenses, and various treatments for eye conditions and diseases. However, the extent of the coverage can vary significantly between different Medicare Advantage Plans, so it’s important to review and compare plan details to ensure your needs are met.
Additionally, while these plans might offer broader coverage, they may also come with different costs, provider networks, and restrictions, so understanding these details is crucial for making an informed decision.
How Much Does Ophthalmology Cost With Medicare?
If you just have Original Medicare, your cost-sharing for Ophthalmology services will fall under Part B of Medicare. Once you reach your $240 deductible, you will have a straight 20% coinsurance for covered services.
A Medicare Advantage Plan, on the other hand, determines your cost-sharing amounts and varies from plan to plan. This can look like a fixed copay or coinsurance, but it will never exceed what your cost-sharing would be if you had only Original Medicare.
Other Options For Coverage
A Medicare Advantage Plan is not your only option if you have Medicare and want vision coverage. There are a couple of different avenues you can also explore, such as:
- Medigap: This will only help pay for Medicare-approved services, but it can help you pay your Part B deductible and coinsurances to offset your expenses. You will pay a monthly premium plus your Part B premium. These plans do not have a network, so you may see any provider that accepts Original Medicare.
- Private vision insurance: This stand-alone vision plan will help you pay for your routine eye care. You will have a separate premium and copays/coinsurance to minimize costs. Some plans also have a deductible and provider network. Keep in mind that these plans will not coordinate with other insurance like Medicare.
See It In Action
Let’s say you have seen an ophthalmologist concerning the possibility of cataracts. For this first visit, you will pay the Medicare-approved visit fee until you have reached your Part B deductible (which will be $240 in 2024). Once the doctor has deemed cataract surgery as a medically necessary service, you can then schedule the procedure, which will take place in an outpatient setting.
For the procedure itself, you will be approved to receive an Intraocular Lens (IOL) using traditional techniques or lasers. Remember that if you still need to satisfy your Part B deductible, you will pay the remaining amount, plus a 20% coinsurance after it is met. If the surgery costs $3,000, you will pay $600 after the $240 deductible. Since this does not require an inpatient hospital stay, you will only be using Medicare Part B.
Once you have completed your surgery, Medicare will pay for one pair of standard eyeglasses or a set of contacts (for which, again, you will pay a 20% coinsurance fee). Any upgrades like a different style of frames, scratch coating, or anti-glare protection will be your responsibility to pay on top of your 20% coinsurance.
All in All
All in all, Original Medicare does cover ophthalmology visits, but they must be deemed medically necessary, and you will be responsible for your Part B deductible and coinsurance, plus 100% of the cost of any non-covered services.
Additional coverage, such as a Medicare Advantage Plan or private vision insurance, will help you pay for non-covered routine vision care like eye exams, glasses, and contacts. On the other hand, a Medigap policy will only help pay for Medicare-covered eye care.
Frequently Asked Questions