Original Medicare does not include coverage for routine eye exams unless an individual is identified as being at a high risk for eye diseases. However, it’s worth noting that many Medicare Advantage plans offer some level of coverage for vision care. Given that certain eye conditions may not exhibit noticeable symptoms in their initial phases, when timely treatment could mitigate or prevent vision loss, it is advisable for anyone eligible for Medicare to seek avenues for regular eye examinations.

When does Medicare provide coverage for vision examinations?

Although Medicare does not cover routine vision exams, it does provide for eye checkups when related to specific medical issues. Medicare will bear the cost of regular tests if an individual is at risk for or has been diagnosed with conditions such as diabetes, glaucoma, or macular degeneration. For those without these conditions under Original Medicare, the full expense of a routine eye exam, typically ranging between $170 and $200, must be covered personally.

Does Medicare extend coverage to eyeglasses or contact lenses?

In most instances, Original Medicare does not cover the cost of corrective lenses. However, there is an exception: Medicare Part B may cover a single pair of eyeglasses or contact lenses if deemed necessary after cataract surgery. It’s important to note that for options beyond standard glasses, such as tinted lenses or scratch-resistant coating, any additional costs would be the responsibility of the individual.

What Medicare plans include vision care and eye exams? 

Vision benefits are offered by Original Medicare, Medigap, and Medicare Advantage; however, the extent of coverage depends on the plan type and the insurance provider. Among these options, a Medicare Advantage plan generally provides the most comprehensive coverage for vision care.

How much does Medicare contribute to vision care expenses? 

Medicare covers 80% of the Medicare-approved expenses for vision services, procedures, and supplies, including eyewear. If Original Medicare is your sole insurance, you are responsible for the remaining 20% after meeting your deductible. For instance, if a glaucoma test costs $80, your portion would be $16.

When obtaining vision care at an outpatient hospital, an additional hospital copay is incurred. This copay varies but will not exceed the Medicare Part A deductible amount, set at $1,632 for 2024.

Medicare-participating providers and suppliers agree to accept a payment generally lower than their standard fee. Opting for a participating provider results in your payment being based on this reduced amount, ultimately lowering your overall expenses.

How does Medicare Advantage handle vision coverage? 

Medicare Advantage plans offer, at a minimum, the same vision coverage as Original Medicare, with many plans extending benefits to include routine eye exams and eyewear.

At the baseline, Medicare Advantage plans match the vision benefits provided by Original Medicare. This encompasses coverage for eyewear post-cataract surgery, prosthetics, and care related to diabetes, glaucoma, and macular degeneration. Numerous Medicare Advantage policies go beyond Original Medicare coverage, incorporating additional benefits like regular vision exams and eyewear. It’s crucial to review plan documents to identify a policy aligning with your specific needs and budget due to variations in costs and coverage.

How do Medigap plans address vision care expenses? 

Medigap plans are structured to contribute to health costs, including vision care, solely if Medicare extends coverage to the particular charge.

When Medicare covers the service, it assumes 80% of the cost. Depending on the specific policy, your Medigap plan will offset a portion or the entirety of the Medicare deductible and your 20% coinsurance.

Medigap plans cover your remaining balance, typically the 20%, with only a few exceptions. Plan K covers only 50% of your costs, while Plan L covers 75%. Plan N addresses the full 20% and then imposes a copay.

In the event that Medicare denies a claim, Medigap does not contribute to any of the costs, leaving you responsible for the entirety of the charges. For instance, if Medicare approves a $100 charge for the vision services you received, Medicare would cover 80%. Assuming you’ve met your Part B deductible, the remaining 20%, or $20, would be your responsibility. The coverage for this cost would depend on your Medigap plan, covering it in full or in part.

What should I do if I require vision care not covered by Medicare? 

In the event that your Medicare plan does not cover the necessary care, the National Eye Institute website provides a list of valuable resources offering free or low-cost eye care.

Another option to explore is enrolling in a private vision plan or opting for a discount program. Private plans typically provide various benefit levels, spanning from routine to specialty care, allowing you to customize your coverage according to your specific requirements. When assessing these plans, it’s important to be mindful of coverage limitations, network constraints, and out-of-pocket expenses such as deductibles and copays.