It’s estimated that approximately 12 million people over the age of 40 in the United States have some form of vision impairment.
Of this, 1 million are blind, 3 million have vision impairment after correction and 8 million have impaired vision resulting from uncorrected refractive error.
This article will cover different types of Medicare options available and how you can get coverage for routine eye exams.
The federal Medicare program is a government-sponsored health care plan for individuals aged 65 or older, disabled people, and those that suffer from ESRD (End-Stage Renal Disease).
Medicare Part A refers to inpatient treatment and hospital care and includes hospital stays, hospital treatments, and general nursing costs.
Medicare Part B relates to outpatient or general medical coverage and includes preventive treatments, doctor’s consultations, scans, and tests.
Part C/Medicare Advantage Plans are health cover plans offered by insurance companies that have a contract with Medicare. These policies cover Part A, B, and D expenses, including costs for hospital care, prescription drug coverage, and doctor’s visits.
Standalone Part D plans (Prescription Drug Plans) cover self-administered prescription drugs. For example, medications for high blood pressure, pain tablets, and antidepressants.
Medicare Supplement Insurance, also known as Medigap, are licensed health insurance plans for people who have Original Medicare. These plans cover costs such as deductibles, coinsurance, and out-of-pocket costs.
Routine vision checks, annual eye exams, and eye tests for eyeglasses or contact lenses are generally not covered under Original Medicare (Part A and B).
However, Part B will cover routine eye exams and certain expenses if the procedure is deemed to be medically necessary 一 health care services that a health care provider, using clinical judgment, would provide to a patient.
For example, if the patient has diabetes or is at risk for glaucoma they can go for an annual eye exam. Medicare Part B will also cover diagnostic tests and treatments for particular eye or vision diseases such as aflibercept, Lucentis, and ocular photodynamic therapy.
Part B will contribute toward one pair of corrective glasses or one set of contact lenses following cataract surgery to implant an intraocular lens.
Once the patient has paid the annual deductible ($233 in 2022), Part B will reimburse 80% of the Medicare-approved amount for the glasses.
You will only receive coverage if your treatment is approved and given by an eye expert who accepts Medicare. The remaining 20% will be paid by you.
If a patient has diabetes, Part B will cover an annual exam for diabetic retinopathy. This is a disease that increases the risk for glaucoma or macular degeneration 一 or other eye diseases that threaten blindness.
However, the exam will only be covered if it is performed by a state-licensed eye doctor.
A state-licensed doctor is a person licensed to practice medicine or osteopathic medicine and surgery in the state that they have been approved to operate in.
This will be covered under Medicare Part B, which means you’ll first have to pay your annual deductible. The patient will also have to pay 20% of the costs while Medicare covers 80%.
It is important to note that if your doctor suggests more tests, this service is only covered once a year.
Medicare Part B generally provides coverage for an annual glaucoma exam — only if practiced by a doctor licensed to perform in your state.
The coverage will only be approved if the patient has any of the following disease/s:
Family history of glaucoma
Age 50 or over and African American
Age 65 or over and Hispanic
Glaucoma is a group of infections that can damage the eye’s optic nerve and cause vision loss and blindness. Glaucoma usually occurs due to high eye pressure but can also be triggered with normal eye pressure.
Loss of vision can progress quickly but the pain and discomfort caused often leads patients to seek early medical attention which helps to avoid permanent damage.
If your eye/s are impaired following an accident, Medicare usually helps cover the eye exams and tests to diagnose and treat the injury.
Original Medicare covers eye and vision-related procedures when a doctor qualified to operate in your state decide it is medically necessary.
Some of these required procedures include:
Eye infections such as conjunctivitis
Cataract surgery and related pre and post operations
Allergies that impact the eyes
Injuries to the eyes or related areas.
If your eye injury or issues require a hospital stay, Part A will cover your first 60 days in hospital once you have met the required deductible.
If you have, or your doctor suspects you have Macular Degeneration, often called Age-Related Macular Degeneration (AMD), Medicare Coverage Part B typically covers exams, tests, doctor visits, and certain prescribed drugs related to the disease.
After your Part B detectable has been met, 80% of the allowable charges will generally be covered.
Macular degeneration, or age-related macular degeneration (AMD), is an eye disorder linked with aging. AMD is a common disease for people over the age of 50 that causes damage in the center of the field of vision.
Central vision is needed to see objects clearly and to complete daily tasks like reading and driving.
For people over the age of 65, AMD is the leading cause of permanent damage for fine or close-up vision. In 2020 it was estimated that 2.95 million had AMD.
By 2050, the number of people in the U.S. with cataracts is expected to double from 24.4 million to about 50 million. If your doctor believes it is medically necessary Medicare will pay for a cataract eye exam.
The payment for cataract diagnosis and treatment will usually be covered by Medicare plans. This includes cataract surgery.
Medicare typically pays allowable charges related to diagnosis and treatment of cataracts, including the surgery if it is done through traditional surgical techniques or the use of lasers.
After surgery, Medicare Part B helps cover one pair of prescription eyeglasses or contact lenses if you have cataract surgery with an intraocular lens implant.
A cataract is a clouding of the eye’s lens and is the leading cause of vision loss and blindness worldwide. Cataracts can occur at any age due to its many different causes and can sometimes be present from birth.
It is estimated that 20.5 million Americans aged 40 years and older have cataracts in one or both eyes. The total number of people who have cataracts was estimated to increase to 30.1 million in 2020.
Eye Exam coverage from Medicare
The table below summarises the various types of eye diseases and what Medicare can do to help.
|If you have:||Original Medicare (Part A and B):||Coinsurance:|
|Diabetes||Eye exam once every 12 months for diabetic retinopathy.||20% of allowable charges after you meet your Part B deductible.|
|Macular degeneration||Diagnostic eye exams and tests as often as your state-approved doctor deems it is medically necessary.||20% of allowable charges after you meet your Part B deductible.|
|Glaucoma Risk Factors (family history of the disease, diabetes, or are of African American or Hispanic descent)||Glaucoma test once every 12 months.||20% of allowable charges after you meet your Part B deductible.|
|Cataracts||Diagnostic eye exam if your state-approved doctor deems it is medically necessary||20% of allowable charges after you meet your Part B deductible.|
|Eye Injuries||If your eye/s are impaired following an accident or injury, Medicare usually contributes towards eye exams and tests to diagnose and treat the injury.||Original Medicare covers eye and vision-related procedures when a doctor qualified to operate in your state finds it medically necessary.|
Commonly, the only way to cover routine Medicare eye exam coverage is through their Advantage Plan, also known as Part C.
Medicare Advantage plans are sold by Medicare-approved companies that offer coverage for Part A, B, and D expenses.
Every Medicare advantage policy, under federal law, has to include all the benefits under Medicare Part A and B, but they can offer additional coverage for different members which may include eye care.
Most Medicare Advantage plans offer additional benefits and coverage — including vision coverage.
If your Medicare Advantage policy offers vision benefits for routine yearly eye exams, you might have to pay a copayment amount for these exams.
However, if you are required prescription eye drops or other related medication, Medicare Advantage plans commonly also include Part D coverage for prescription drugs.
Not all Medicare Advantage plans offer routine eye exam benefits.
If you already have a Medicare Advantage policy, be sure to double-check your paperwork or reach out to the team at PolicyScout by email or telephone to answer your questions regarding Medicare plans.
Medicare Supplement Insurance Plans are insurance plans that cover some of Medicare’s out-of-pocket expenses.
Out-of-pocket expenses: These are any expenses that aren’t covered by Medicare which you will have to pay for.
Some examples include:
Deductibles: An amount of money that you must pay before your Medicare coverage begins.
Coinsurance: A portion of the costs of treatment that you are responsible for.
These are only available for people who are already with Original Medicare but not those with Medicare Advantage Plan.
For approved Medicare vision procedures and services, Medicare Supplement plans will contribute and help you pay the required deductible and coinsurance. The exact amount will depend on your specific plan.
Medigap does not provide additional Medicare vision coverage compared to what is offered through Original Medicare coverage, but some Medicare Supplement plans may cover vision-related costs or additional eye coverage for an extra fee.
Eyecare is such an overlooked but important part of your medical care, and PolicyScout wants to ensure that you find the best coverage for your eyes.
If you are looking for up-to-date and accurate information about Medicare, Medicare Advantage, and Medicare Supplemental Insurance, head to PolicyScout’s Medicare Hub to compare your options and find the best plan for you.
We can also connect you with some of the best Medicare Advantage providers in your area if you’re ready to look into different Medicare Advantage plans.