Medicare and Eye Exams: Seeing the Coverage Clearly

Generally speaking, Original Medicare (parts A and B) doesn’t cover routine eye exams. However, some types of other eye exams may be covered. These can include:

Eye exams for those with diabetes

People who have diabetes can develop a condition called diabetic retinopathy. This happens when elevated blood sugar levels lead to damage of the blood vessels supplying your retina. It can cause vision loss.

If you have diabetes,Medicare will cover eye exams to detect diabetic retinopathy once per year.

Glaucoma tests

Glaucoma is a condition the involves damage to the optic nerve, potentially causing vision loss. As you get older, your risk for glaucoma increases.

Medicare covers tests for glaucoma once every 12 months for groups that are at a high risk for developing glaucoma. You may be at high risk if you:

• have a family history of glaucoma
• have diabetes
• are African American and are age 50 or older
• are Hispanic and are age 65 or older

Macular degeneration tests and treatment

Macular degeneration is a condition that causes loss of vision that helpsyou to see objects in front of you. This can affect activities like driving andreading.

Medicare may cover some diagnostic tests and treatments if you have macular degeneration that’s related to aging. This can also include things like some types of injected drugs.

Cataract surgery

Cataractsoccur when the lens of your eye becomes clouded. Since the lens helps your eyeto focus images, the presence of cataracts can make your vision blurred, cloudy, or faded.

Medicare covers some aspectsof cataract surgery, including:

• the placement of an intraocular lens (IOL), a small clear disc that replaces a lens that has become clouded with cataracts
• a pair of eyeglasses or contact lenses following each IOL insertion surgery
• the costs of facilities and provider services for the placement of an IOL

Medicare only covers the placement of a conventional IOL. Some types of IOL correct astigmatism or presbyopia. Medicare won’t pay for facility or provider services related to insertion or adjustment of these specific types of IOLs.

There are several parts of Medicare that may cover vision care.

Medicare Part A

This part covers stays inthe hospital or other inpatient facilities, such as skilled nursing facilities.If an eye condition requires admittance to the hospital, Part A may cover yourstay.

Most people don’t pay apremium for Part A. When you’re in an inpatient facility, the amount you pay incoinsurance is based off of the type of facility and the length of your stay.

Medicare Part B

Medicare Part B covers thefollowing:

• doctors’ services
• outpatient care
• preventive care
• medical devices

After meeting a yearlydeductible, you’re typically responsible for 20 percentof the Medicare-approved costs. This part of Medicare covers the eye exams thatwe’ve discussed above, which include:

• eye exams for people with diabetes once per year
• glaucoma testing in high-risk groups once every 12 months
• age-related macular degeneration testing and treatment
• placement of conventional IOLs during cataract surgery, eyeglasses or lenses after the procedure, and the cost of facilities and services

Medicare Part C

You may also see Medicare Part C referred to as a Medicare Advantage plan. Private companies that have been approved by Medicare provide these plans.

Part C offers all the benefits of parts A and B. Most of them also include Part D (prescription drug coverage) as well. Some Part C plans offer additional benefits like vision and dental.

It’s likely that a Part C plan that includes vision benefits will include things like:

• routine eye exams
• eyeglass frames and lenses
• contact lenses

The premiums, costs, and types of services provided by Part C can vary by plan. It’s important to carefully compare Part C plans before selecting one.

Medicare Part D

Medicare Part D is an optional plan that includes prescription drug coverage. Like Part C, Part D is offered by private companies that have been approved by Medicare.

Medications required for eye care may be covered under Part D. Examples include medications for glaucoma, dry eyes, or eye infections.

Premiums, copayments, and the types of drugs that are covered can be different depending on the plan. Compare Part D plans to ensure the medications you need are covered.

Overall, the cost of an eye exam can depend on several factors, including:

• Your type of insurance. What’s covered can vary by your specific plan.
• Charges from the doctor or facility you visit. Some doctors or locations may charge more than others.
• What types of tests are performed. Specialized tests or getting fitted for eyeglasses or contact lenses may cost more.

To help estimate the costs, contact your insurance provider in order to find out what services are covered. For Medicare, Part B will cover select types of eye exams while Part C coverage will depend on your specific plan.

Next, ask about the total costof the exam as well as what tests are included when selecting a doctor orfacility. You can use this information with the information from your insuranceprovider to estimate how much you’ll owe.

If you’re concernedabout the costs of eye exams or eye care, there are a variety of resourcesavailable to you. The National Eye Institute has a list of programs thatcan help with the cost of eye care.

So how do you know whichplan is right for you if you know you’ll need an eye exam? It’s importantto consider your specific needs when selecting a plan.

Part B will only covercertain types of eye exams, often for people in at-risk groups. If you’re inone of these groups, Part B may be sufficient to meet your needs.

Additionally, Part B covers the placement of IOLs in cataract surgery. If you know that you’ll need cataract surgery in the future, you may want to select a Part B plan.

If you know you’ll needroutine eye exams, eyeglasses, or contact lenses, you may want to look into aPart C plan. Many of these plans include vision benefits that aren’t includedwith just Part B alone.

If you use medication for an eye condition, such as glaucoma or dry eyes, consider enrolling in Part D. This can help cover the cost of these medications.

Tips for helping a loved one enroll in Medicare

Are you helping a loved one to enroll in Medicare? Follow the tips below:

• Know if they need to sign up. Individuals collecting Social Security benefits will be automatically enrolled in parts A and B when they’re eligible for Medicare. Those that aren’t collecting will need to sign up starting 3 months before they turn 65.
• Be aware of the open enrollment period. This is when they can make changes to their coverage. It’s from October 15 through December 7 every year.
• Discuss their needs. Every person is different and has different health needs that may help inform the selection of a plan. For example, someone that wears eyeglasses or contact lenses may opt for Part C, which can provide coverage for these items.
• Compare different plans. If you’re interested in enrolling in Part C or Part D, compare several plans to find one that meets their specific financial and health needs.
• Provide information. Social Security may ask for some personal information as well as your relationship to the person you’re helping. Your loved one will need to sign the Medicare application themselves before it’s submitted.

Many older individuals useeyeglasses or contact lenses to help with their vision. In fact, a 2018 studyfound that an estimated 92.4 percentof people 65 and older and enrolled in Medicare reported using eyeglasses tohelp with their vision.

However, Medicare Part Bdoesn’t cover eyeglasses or contact lenses. Part B only covers these items ifthey’re provided following a cataract surgery where an IOL is placed.

Many Medicare Part C(Medicare Advantage) plans have vision benefits that may cover eyeglasses andcontact lenses. If you know that you’ll need these things, it may be a goodidea to look into enrolling in a Part C plan.

Eye exams are an important first line of defense against conditions like glaucoma or cataracts. Timely identification and treatment can help prevent vision loss.

MedicarePart B only covers certain types of eye exams, mostly in groups that are athigh risk for certain conditions. Part B also covers some aspects of cataractsurgery.

In addition to including coverage provided by parts A and B, Medicare Part C plans may have additional vision benefits. These can include things like routine eye exams, eyeglasses, and contact lenses.

When selecting a Medicareplan, carefully consider both your health and financial needs. You may need tocompare several plans in order to find that one that’s right for you.