Risk of eye disease increases with age, but what does Medicare cover? When you’re considering your Medicare options, make sure you understand vision coverage so you can plan for how to pay for your eye-care needs.
If you live long enough, chances are you will have some vision loss or impairment. Nearly two-thirds of people over 40 experience vision impairment or other problems like age-related macular degeneration, cataracts, glaucoma, or diabetic retinopathy.2 Vision loss can increase the risk of falls and injuries, as well as lead to psychological problems like isolation and depression.3
Though most on Medicare will need vision care, Original Medicare offers few vision benefits. Just 4% of Original Medicare beneficiaries buy stand-alone vision plans, while 67% of people with Medicare Advantage, also known as Part C, get vision coverage through their plan.4 Medicare Advantage is provided by private insurance companies.
How much does vision coverage cost? Medicare beneficiaries with supplemental vision plans paid an average of $415 out-of-pocket for vision care, compared with $331 for those with Medicare Advantage.5
Does Medicare Cover Eye Exams?
Original Medicare does not cover routine eye exams,6 though most supplemental vision plans and most Medicare Advantage plans do.
Medicare Part B — which handles doctor visits and other outpatient services — only covers “medically necessary” eye exams, such as for people with diabetes.
Does Medicare Cover Eyeglasses or Contact Lenses?
Original Medicare does not cover eyeglasses or contact lenses; without a stand-alone vision plan or Medicare Advantage, you pay 100% of the costs.8
Cataract surgery treats a condition that makes the lens in your eye cloudy and can affect your vision. If you have cataract surgery, Part B will pay for your eyeglasses or contact lenses following that surgery.
What Else Does Medicare Cover?
Medicare covers care related to eye disease or injury. For example, Medicare covers medically necessary treatment, such as medication or surgery, for conditions like:
- Dry eyes and allergies.
- Eyelid problems.
- Eye infections (like conjunctivitis).
- Corneal disease.
- Detached retina.
- Eye injuries.
What Vision Benefits Does Part A Cover?
Medicare Part A covers hospitalizations or inpatient care. If you need eye surgery that cannot be done in an office or clinic, Part A covers your hospital stay after you pay the deductible, which is $1,408 in 2020.11 For a hospital stay of fewer than 60 days, you would not pay any additional copayment or coinsurance.12
What Vision Benefits Does Part B Cover?
Though Medicare Part B does not cover routine vision care, it does cover some vision care and testing.
Medically necessary coverage
Some people, including people with diabetes, are at higher risk of certain eye diseases, like:
- Glaucoma, which damages the optic nerve through fluid build-up.13
- Diabetic retinopathy, in which high blood sugar can damage blood vessels in the retina and ultimately cause vision loss.14
Given these risks, yearly eye exams are considered medically necessary and are covered by Part B. You must get your eye exam from an eye doctor who participates in Medicare.
Even if your exam is covered, it isn’t completely free. With Part B, you pay 20% of the bill at your doctor’s office, or a copayment if you get the exam at a hospital outpatient clinic. Your Part B deductible applies. You could also enroll in a Medicare Supplement plan that could help cover the cost of the deductible.15
Some tests and screening
Medicare Part B covers tests for glaucoma every 12 months if you’re considered high risk, meaning:
- You have diabetes.
- You have a family history of glaucoma.
- You are African American and 50 or older.
- You are Hispanic and 65 or older.
If Part B covers your glaucoma test, you must pay your deductible and then pay 20% of the Medicare-approved amount. Depending on where you get the glaucoma test, you may also have a copayment.16
Age-related macular degeneration (AMD) is a condition that affects the part of your retina called the macula. AMD can cause loss of central vision, which makes it hard to focus on objects straight ahead.17
Diagnosing AMD may require a dilated eye exam that allows your doctor to look inside your eye. Other tests to identify AMD include a retinal scan or a test to study the blood vessels in your eye.18
Medicare Part B covers certain tests and treatments if you have AMD. You pay 20% of the Medicare-approved amount for tests and treatments that a Medicare-approved doctor performs after you’ve met your deductible. If you get AMD testing or treatment in a hospital clinic, you also have a copayment.19
Typically, an eye doctor (ophthalmologist) performs cataract surgery in an office or clinic. One study of more than 500,000 cataract surgeries found that 73% took place in an ambulatory surgery center.20
These surgeries fall under Medicare Part B. Roughly a quarter of cataract surgeries — those that require hospitalization — fall under Medicare Part A.
Medicare covers traditional or laser surgery to fix cataracts.
Under Medicare Part B, eyeglasses, and contact lenses after cataract surgery are considered prostheses. Part B covers approved prosthetics; you pay 20% of Medicare-approved fees after you satisfy your deductible.21
What Vision Benefits Does Medicare Advantage Cover?
Medicare Advantage (MA) plans usually offer extra benefits in addition to Original Medicare coverage. Most MA plans — 87% — offer some kind of vision coverage. These plans typically cover exams, eyeglasses, contact lenses, and diagnosis and treatment of eye issues, but costs and coverage vary by plan.22
What Vision Benefits Does Medicare Part D Cover?
You may need medications for an eye infection, allergies, or conditions like glaucoma or macular degeneration, or to diagnose and prevent eye diseases.
Eye medications often require a prescription. Some — like artificial tears, eye drops, and ointments — may be available over-the-counter, though you’ll need a prescription for Medicare to cover it.23
Medicare Part D covers medications via stand-alone Part D plans or MA plans.24 In 2019, 45 million people had opted for Part D coverage in 2019; almost half were in prescription drug plans (PDPs).25 Costs, policies, and covered medications vary widely depending on the plan.26
Eye problems are incredibly common, and increase with age. Eye care is important to overall health and well-being. To make sure you can access the care you need — routine or otherwise — understand your Medicare coverage options so you can get the right coverage for you.