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Does Medicare Cover Eye Exams?

20th September 2023 Print

Regular eye exams are essential for optimal health, especially as you start to get older. The average age that someone starts to use Medicare is at 65. Once you reach your 65th birthday, you should plan to get an eye exam once every year or two since you are at an increased risk for various eye conditions, such as glaucoma and cataracts. However, Medicare is a bit tricky to navigate when it comes to eye exams. Learning more about what they will cover and what your possible out-of-pocket costs will be makes it easier to plan your healthcare goals.

Routine Eye Examinations

If you need a basic eye exam to get contacts or glasses, Medicare will not typically cover it. However, there are some exceptions to this rule. If you have certain medical conditions that may affect your eyes, a routine eye exam may be covered by Medicare Part B. For example, if you need follow-up care following cataract surgery or you have diabetes which can affect eye health, your routine eye exam may be covered.

Disease-Related Eye Examinations

If you have certain health conditions and meet certain related criteria, you might qualify for covered eye exams via Medicare. Diabetes can cause vision loss by damaging the retina's blood vessels. Referred to as diabetic retinopathy, Medicare will cover one exam a year to help catch this condition quickly should you develop it.

If you meet certain criteria that puts you at risk for glaucoma, Medicare will cover one glaucoma test every 12 months. The criteria include:

- Family history of the disease
- You are 50 or older and African American
- You have diabetes
- You are 65 or older and Hispanic

Macular degeneration can affect daily activities like reading and driving. If the condition is related to aging, some of the diagnostic tests might be covered by Medicare. If your doctor suspects that you might have this condition, you should talk to a Medicare representative. They can see exactly what your doctor says, and it will be easier to determine if you qualify for related coverage.

Medicare does cover some elements related to cataract surgery. Medicare may cover the following cataract surgery aspects:

- Getting an intraocular lens placed
- Coverage for the provider services and facilities where the surgery occurs
- Contact lenses or glasses after intraocular lens insertion

Medicare Parts and the Associated Coverage

There are different parts of Medicare coverage and understanding how these parts may or may not cover eye care helps you to make the right decisions scheduling your healthcare appointments.

If you have to stay in a hospital due to an eye condition, Part A may cover part of your stay. You will likely still have a coinsurance payment based on how long you have to stay and the type of facility you are at.

Part B is the part that may offer some coverage if you have a condition that affects your eyes (the ones listed above). Typically, you will only have to pay 20 percent of the costs approved by Medicare after you meet your annual deductible.

Medicare Advantage, also referred to as Part C, may help with some eye-related benefits. Part C includes everything that Part A and Part B offer, but private companies approved by Medicare provide the plans. You also usually have Part D as part of this plan. Depending on the Part C plan that you choose, you may have some coverage for the following:

- Eyeglasses and frames
- Routine eye exams
- Contact lenses

Medicare and Eyeglasses

Since an estimated 92 percent of people older than 65 require eyeglasses, you want to know if Medicare will provide some coverage to pay for them. There are some Part C plans that have the vision benefits that could extend to contacts and glasses. If you already require corrective lenses when you sign up for Medicare, it is best to really evaluate all of the plans to see which ones provide the right amount of coverage for you.

Part D is coverage for prescription drugs, and it is optional. If your doctor prescribes any medicine for an eye condition, the costs could be covered through Part D. There are different Part D plans, so if you think you might need eye-related medicines, make sure to explore the plans thoroughly to choose the one with the most appropriate coverage.

When it comes time for eye examinations, let your doctor know that you have Medicare. They can further help you to determine if your next exam will be covered. If not, they may know of some resources to help seniors with basic eye exams, and any contacts or glasses if it is determined that they are needed to improve your eyesight.

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