When it comes to health, your eyes can certainly tell a story about your overall well-being. As you get older, that story gets more chapters — and becomes more complex.
Staying on top of your eye health is important, but Medicare doesn’t cover all vision care needs. Before you head to the eye doctor for a vision check or medical eye exam, you should know what might be covered and what you’ll have to pay for out of pocket.
[SEE: Things You Should Know About Medicare.]
Importance of Regular Eye Exams for Overall Health
As you age, your eyes change, and your ability to see objects up close or far away often shifts. Routine eye exams or vision tests can help you preserve your vision longer.
Staying up-to-date with corrective lens prescriptions can also help keep you safe. Driving at night without glasses, for instance, may be impossible for some people.
What’s more, during a routine eye exam, your provider might notice an eye issue that needs to be addressed medically, such as diabetic retinopathy.
“Vision care is important to a lot of seniors,” says Bob Rees, vice president of Medicare sales and member loyalty with eHealth Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California. “It’s a common frustration among Medicare beneficiaries that Original Medicare does not cover routine eye exams.”
[READ: How Often Should a Full Eye Exam Be Done?]
Does Medicare Cover Eye Exams?
In short, no, Medicare does not cover routine eye exams for eyeglasses or contact lenses. Medicare also does not cover the cost of glasses or contacts unless you’ve just had cataract surgery.
Does Medicare Part B pay for eye exams?
Medicare Part B, the medical insurance component of Medicare, does not pay for everyday vision care.
“Unfortunately, while eye exams are preventative in nature, Original Medicare Part A or Part B does not cover routine eye exams,” confirms David Luna, a licensed Medicare agent and president and co-founder of Connie Health, a platform that helps seniors connect with a local agent to choose a Medicare plan.
This means that if you need a new eyeglasses or contact lens prescription, Medicare won’t cover the cost of that exam.
Medicare’s eye exam coverage explained
There are some situations where certain services may be covered by Medicare, says Yuna Rapoport, a board-certified ophthalmologist and founder and CEO of Manhattan Eye, a New York-based ophthalmology practice that treats Medicare patients.
These cases are not the same as routine vision care visits. Rather, they’re about identifying potential medical conditions.
“Medicare covers a complete medical eye exam, which includes a slit lamp and dilated fundus exam, vision, pressure, glaucoma, cornea and macular degeneration testing,” Rapoport explains.
If you have diabetes-related vision problems, Medicare covers one annual exam by an eye doctor licensed in your state.
Medicare also covers one yearly eye exam by a state-authorized eye doctor if you have a high risk for glaucoma. The high-risk category includes:
— Those with diabetes.
— Those with a family history of glaucoma.
— Those who are African American and age 50 or older.
— Those who are Hispanic and age 65 or older.
“Medicare Part B will only cover an eye exam to diagnose potential vision problems, but the exam is covered even if you don’t have a vision problem,” Luna says.
[Read: 5 Steps for Picking a Medicare Plan.]
Does Medicare Advantage Cover Eye Exams and Vision Care?
Some Medicare Advantage plans do cover routine vision care and eyeglasses. Each plan has its own set of options, so check the fine print in your plan to understand what benefits are available to you.
Medicare vs. Medicaid: Vision Care Comparison
Medicare is a federal health insurance program designed for people over age 65. Certain individuals under age 65 with disabilities who meet certain criteria may also be eligible for health care coverage via Medicare..
Medicaid, on the other hand, is a joint federal and state health insurance program designed for low-income people regardless of age. Eligibility for Medicaid depends on specific income and other criteria as set by the state where you live.
For those who qualify, Medicaid offers health insurance benefits for a variety of conditions and services. Some states, for instance, have preventive eye health programs designed for adults, and some states also cover glaucoma or other eye disease health screenings. Like Medicare, Medicaid covers part of the cost of cataract surgery.
In all cases, benefits provided by Medicaid vary by state, so you’ll have to connect with a local agent or adviser to help you understand what’s covered by Medicaid where you live.
Navigating Eye Exam Expenses
An annual vision test is always a good idea, and if you wear glasses, it’s particularly important to make sure that your prescription stays current.
Because Medicare doesn’t cover the cost of routine eye exams, you’ll have to pay for these exams out of pocket or find a supplemental insurance plan to help defray the costs.
Out-of-pocket expenses and tips for affordability
Luna notes that an eye refraction exam, which measures your corrective lens prescription, “could cost around $60, but you’ll also need to account for the (general) patient exam. If you’re a new patient, that could cost $250. If you’re an existing patient, that’s usually a little less, an average of $155.”
After your doctor finishes your exam, you may need new corrective eyeglass or contact lenses.
“Most people pay between $100 and $150 for their prescription eyeglass frames,” Luna says.
Medicare Part A and Part B do not cover the cost of eyeglasses or contact lenses, which means those will be out-of-pocket expenses.
In total, “you’re looking at $315 out of pocket for the eye exam and a new pair of prescription glasses at the low end,” Luna adds. “The cost depends on the exam and choosing basic or upgraded frames and lenses.”
Do I need supplemental insurance for eye exams?
Because traditional Medicare and Medigap plans don’t cover the cost of routine eye exams, eyeglasses or contact lenses, you may be considering a supplemental insurance plan, such as a Medicare Advantage plan, to help cover the costs.
“Medicare Advantage plans offer the same benefits as Medicare Part A and B, but with extra benefits. These often include vision, dental and hearing,” Luna explains. “Many Medicare Advantage plans have a $0 monthly premium and may offer a vision benefit for eye exams and prescription eyeglasses or contacts.”
Rees adds that if Medicare Advantage isn’t right for you, you can purchase your own vision insurance plan. A licensed agent can help you sort through the options.
“Just keep in mind that the coverage provided through vision plans is typically limited to specific payouts for biannual exams and limited coverage for glasses or contacts,” Rees advises. “You’ll want to do your own cost-benefit analysis to see if the monthly premiums and annual benefits make sense for you.”
FAQs
What Medicare covers specifically — medical eye exams, for instance — should be part of your decision-making process, especially if you need to budget for these visits.
Does Medicare cover diabetic eye exams?Medicare Part B does cover eye exams for diabetic retinopathy — a serious condition in which chronic high blood sugar levels damage the retina — once each year if you have diabetes. The exam must be performed by an eye doctor who’s legally allowed to do the test for this condition in your state.
Does Medicare Part B cover eye exams?Medicare Part B covers an annual medical eye exam to assess for cataracts, glaucoma and macular degeneration and for retinopathy care for people with diabetes. It does not cover routine vision care exams or corrective lenses.
Does Medicare cover eye exams and glasses?Medicare does not cover routine eye exams for glasses or contact lenses.
Does Aetna Medicare cover eye exams?Some Aetna Medicare Advantage plans do include vision benefits that may cover the cost of routine eye exams for eyeglasses or contact lenses. Check the specifics of your plan to understand what’s covered for you.
Bottom Line
Rapoport notes that “by the time someone is of Medicare age, they should be getting a routine medical eye exam anyway to assess for cataracts, glaucoma and macular degeneration, and Medicare does cover all of these.”
However, it’s important to note that routine eye exams to check whether your prescription has changed aren’t classified as medical eye exams and aren’t covered. Therefore, it’s important to be clear upfront with your provider about what services you’re looking for and to understand what your financial responsibilities will be after the exam is completed.
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Does Medicare Cover Eye Exams? originally appeared on usnews.com
