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.
Unfortunately, Medicare, the federal health insurance program primarily for those 65 and older, doesn’t cover all your vision care needs.
Before you head to the eye doctor for a vision check or medical eye exam, find out what might be covered and what you’ll have to pay for out of pocket.
[READ: Understanding Age-Related Vision Problems]
Does Medicare Cover Routine Eye Exams?
In short, no, original Medicare does not cover routine eye exams for eyeglasses or contact lenses. Medicare also does not cover the cost of glasses or contact lenses unless you’ve just had cataract surgery.
“It’s a common frustration among Medicare beneficiaries that original Medicare (Part A and Part B) does not cover routine eye exams,” says Bob Rees, chief sales officer with eHealth Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.
“Unfortunately, while routine eye exams are preventative in nature, original Medicare Part A or Part B do not cover them,” confirms David Luna, a Phoenix-based 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.
That means that if you need a new prescription for eyeglasses or contact lenses, Medicare won’t cover the cost of the exam.
Medicare Part B covers field of vision tests if they are medically necessary, adds Terri Wilson, senior vice president of VSP Vision Care, a vision care health insurance company headquartered in Rancho Cordova, California.
[SEE: Do You Need Eyeglasses? Watch for these Common Signs.]
Does Medicare Cover Medically Necessary Eye Exams?
Medicare Part B, the outpatient component of Medicare, does not cover everyday vision care. However, it does cover eye exams for medical conditions like diabetic eye exams, and glaucoma and macular degeneration screenings for high-risk individuals.
These are the high-risk individuals for whom Medicare will cover annual eye care:
— People with diabetes
— People with a family history of glaucoma
— African American patients age 50 or older
— Latino patients ages 65 or older
In those cases, “Medicare covers a complete medical eye exam, which includes a slit lamp and dilated fundus exam, vision, pressure, glaucoma, cornea and macular degeneration testing,” Dr. Yuna Rapoport, a board-certified ophthalmologist and founder and CEO of Manhattan Eye, a New York-based ophthalmology practice that treats Medicare patients.
If you have diabetes-related vision problems, Medicare covers one annual exam by an eye doctor licensed in your state. Diabetic retinopathy is a serious condition in which chronic high blood sugar levels damage the retina. The exam must be performed by an eye doctor who’s legally allowed to do the test for this condition in your state.
Medicare also covers one annual eye exam by a state-authorized eye doctor if you have a high risk for glaucoma.
In addition to the above condition, Medicare Part B will cover exams and treatment related to:
— Eye infections or injuries
— Retinal detachment
Does Medicare cover field of vision tests?
Medicare Part B covers field of vision tests if they are deemed medically necessary. These tests are typically used to diagnose or monitor eye care-related conditions such as glaucoma, macular degeneration or diabetic retinopathy.
Cost of Medicare-covered eye exam
For each of these covered services, you would pay 20% of the Medicare approved amount (called coinsurance), and the Part B deductible applies.
For example: You get a vision test that costs $100 (Medicare-approved amount). If you haven’t met your Part B deductible ($257 in 2025), you pay the full $100. If you have met your deductible, Medicare pays 80% ($80), and you pay 20% ($20). That 20% is your coinsurance. It applies to most Part B services.
[READ: How Often Should a Full Eye Exam Be Done?]
Does Medicare Pay for Glasses or Contacts?
As with routine eye exams, original Medicare does not pay for glasses or contact lenses. This includes most eyeglasses lenses and frames and most contact lenses and contact lens fittings.
However, Medicare Part B will cover one pair of eyeglasses with standard frames or a single set of contact lenses after cataract surgery. Beneficiaries must pay 20% of the Medicare-approved amount after meeting the Part B deductible for these devices.
[READ: Medicare vs. Medicare Advantage: How to Choose.]
Does Medicare Advantage Cover Eye Exams and Vision Care?
Many Medicare Advantage plans (Part C) do cover routine vision care, eyeglasses and contact lenses. Some plans may also cover LASIK surgery. But coverage varies by plan.
For example, some plans offer an in-network benefit, which allows a member to see any vision provider in the plan’s network, while other plans offer a direct member reimbursement benefit, which provides an annual benefit amount to use for covered eyewear.
Because of these variations, it’s important to check your vision benefits when enrolling in a Medicare Advantage plan.
Many Medicare Advantage plans have an annual dollar limit for vision coverage. In 2021, this annual limit average was $160. These plans also have limits on how often you can get a new pair of glasses, usually one pair a year or a pair every two years.
[READ: A Patient’s Guide to Eye Disease.]
Medigap Coverage for Vision Care
Some Medigap supplemental insurance plans can help defray the vision care costs. (There are 10 Medigap plans, but the one that covers the most is Plan G.) Some of these plans will let you add a package of benefits that cover some in-network vision, dental and hearing exams and one pair of glasses or contacts each year, up to an annual limit.
Medicare vs. Medicaid: Vision Care Comparison
Medicare coverage is designed for seniors as well as individuals under age 65 with disabilities who meet certain criteria.
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 may 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.
[HSA and Medicare: Using HSA To Pay for Medicare Premiums]
Other Options to Pay for Vision Care
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.
Other options are a flexible spending account or a health savings account, which let you set aside money before taxes to cover your health care costs, including those related to your eyes. There are even discount vision programs available that can offer reduced costs on eye exams, eyeglasses and contact lenses at participating providers.
Some nonprofits may offer help in paying for vision care. These include:
— EyeCare America
— Lenscrafters Foundation: OneSight
— Lion’s Club International
Out-of-pocket expenses
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 eyeglasses or contact lenses. Of course, prices are going to vary depending on the doctor and also other factors, such as where you live in the country.
“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.”
Regular Eye Exams Are Important 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 — and your independence — longer. Some people stop being able to drive without corrective eyewear, especially at night.
Routine exams help detect early signs of:
— Glaucoma
— Cataracts
— Macular degeneration
— Diabetes-related eye issues, such as diabetic retinopathy
“Early detection and intervention can help prevent or mitigate serious vision problems,” Wilson says.
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originally appeared on usnews.com
