Does Medicare Cover Optometry?

Does Medicare cover optometry? Maintaining healthy eyes throughout life is vital to a person’s overall health and wellbeing. But the truth is that when people reach retirement age and don’t have vision coverage through their health insurance, their eye health can suffer. 

Medicare Benefits Solutions

Jul 15, 2021

 4 minutes read

Because aging may cause eye health to decline, it’s even more important for seniors to have access to affordable vision and eye care. Many Medicare beneficiaries who depend on Original Medicare insurance for health care don’t get the help they need when it comes to many optometry services. 

While Original Medicare Parts A (hospital insurance) and B (medical insurance) cover some medically necessary eye care, it doesn’t help out with routine eye exams, eyeglasses, or contact lenses. On the other hand, many Medicare Advantage plans, also known as Medicare Part C plans, do offer additional benefits for optometry services. Here’s a detailed breakdown of how different parts of Medicare cover eye health care. 

How does Original Medicare cover optometry services?

As mentioned above, Original Medicare doesn’t include benefits for routine eye exams or corrective lenses, and you pay 100 percent of the cost for these services and supplies yourself. However, Medicare Part B does cover the following services:

• Diabetic retinopathy exams on an annual basis if you have diabetes. To be eligible for this benefit, you must have the exam done by an eye doctor who is licensed in your state, and who accepts Medicare assignment. Medicare pays for 80 percent of the cost, and you pay the remaining 20 percent along with your Part B deductible. 

• Glaucoma testing one time every 12 months if you are in the high-risk category. High-risk factors include having diabetes, a family history of glaucoma, being African American over 50 years old, or being Hispanic and over 65. To get this benefit, your health care provider must be licensed in your state and accept Medicare assignment. Medicare pays 80 percent of the final cost, and you pay the remaining 20 percent along with your Part B deductible. 

• If you have age-related macular degeneration, Medicare Part B covers some diagnostic tests and treatment, which can include certain injected drugs, for related eye diseases and conditions. Eligibility requirements and coverage percentages are the same as mentioned above.  

Do Medicare Advantage plans cover optometry services?

As an alternative to Original Medicare, Medicare Advantage plans must offer beneficiaries the same health care benefits as provided by Parts A and B, but many provide extra benefits like dental, hearing, vision, and prescription drug coverage. 

You can enroll in a Medicare Advantage plan from private insurance providers that are affiliated with Medicare. All providers have the option to choose whether to include extra benefits, so you should examine all available options before enrolling in an MA plan if you specifically want coverage for optometry services. 

Vision benefits vary from plan to plan but generally include coverage for routine eye exams, eyeglasses, contact lenses, fittings for frames and lenses, and in many cases, an upgrade in eyeglass frames. 

Your out-of-pocket costs for your vision care coverage depend on what your Part C plan charges for copayments and premiums. You may also need to continue paying your Medicare Part B premium if it isn’t included in your Medicare Advantage plan’s coverage. 

It is also important to note that your Medicare Advantage plan may require that you get all your medical services and supplies through health care providers, physicians, and suppliers that are included in the plan’s network.

If you aren’t sure about your Medicare Advantage plan’s network restrictions, you can find this information in your written policy, at your provider’s online site, or by calling your provider and speaking with a representative. 

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