Let’s get this out of the way first: Only certain Medicare Advantage plans include your typical, “vision benefits.” Original Medicare – which is Medicare Part A and Part B – does not cover routine eye exams. These exams are oftentimes referred to as “eye refractions,” which are obtained for getting eyeglasses or contact lenses.
But, while Part B of Medicare does not cover basic eye examination, it will cover certain types of preventive and diagnostic eye exams. These may include the following a(n):
An annual eye exam may be covered for diabetic retinopathy, provided that it is performed by a doctor who is legally allowed to do the test in your state. All individuals who have both Medicare Part B and who have diabetes are covered for this exam.
The cost for this exam will include 20% of the Medicare approved amount for the doctor’s service, as well as the Medicare Part B deductible. In 2019, the Medicare Part B annual deductible amount is $185. In addition, if this type of eye examination is performed in a hospital outpatient setting, you could also incur an out-of-pocket co-payment.
Medicare Part B may also cover a glaucoma test once every 12 months for those who are considered to be at a high risk for glaucoma. In order to be covered, though, this particular screening must either be done or supervised by an eye doctor who is legally allowed to do the exam in your state.
All individuals who are at high risk for glaucoma and who have Part B of Medicare are covered for this exam. In order to be considered a high risk individual, you will typically have to have diabetes, as well as meet other certain qualifying characteristics.
Your out-of-pocket for this type of eye exam will include 20% of the Medicare approved amount, as well as the annual Part B deductible (if this deductible has not yet been met). Should the exam be performed in a hospital outpatient setting, there may also be a co-payment charged.
Part B of Medicare may also cover various diagnostic testing and treatment of diseases and conditions of the eye. These may include treatment with certain drugs that are injected. Some Medicare Part B enrollees who have age-related macular degeneration are covered for this.
Similar to with the other eye-related exams, the costs for these tests to you will be 20% of the Medicare approved amount for the drug and the doctor’s services, as well as the Medicare Part B annual deductible. Likewise, if the examination takes place in a hospital outpatient setting, you could also be responsible for paying a co-payment.
In order to more closely determine how much a certain vision related test, item, or service may cost, you can discuss the situation with your doctor or other health care provider. The actual amount of the exam can depend on a number of factors, such as other insurance that you may have, how much the doctor charges for the service, whether or not the doctor accepts Medicare assignment, the type of facility the test will be performed in, and / or the location where you will be getting your test, item, and / or service.
Original Medicare (Part A and Part B) does not generally cover either eyeglasses or contact lenses. However, following cataract surgery that implants an intraocular lens, Medicare Part B may help you to pay for corrective lenses. This includes either one pair of eyeglasses or one set of contact lenses. All individuals who are enrolled in Medicare Part B are covered for this particular benefit.
Medicare will only pay for eyeglasses or contact lenses that are provided by a supplier that is also enrolled in Medicare – regardless of who submits the claim.
When getting glasses or contact lenses in this way you may be required to pay 20% of the Medicare approved amount for one pair of glasses or one set of contact lenses after each cataract surgery with an intraocular lens.
In addition, you could be required to pay any additional costs if you purchase items such as upgraded eyeglass frames. And, you will need to pay for 100% of any non-covered services. The Medicare Part B deductible will also apply.
In order to get a better idea of how much your items may cost, you should speak directly with your doctor or your other health care provider. This is because the specific amount that you will owe can depend on a number of different factors.
These criteria can include any other insurance coverage that you may have, the amount that your doctor and / or supplier charges, whether or not your doctor and / or supplier accepts Medicare assignment, the type of facility where you obtain your services, and the location where you get your test, items and / or services.
Your doctor or other health care provider may recommend that you obtain your services or your items from a supplier that is not covered by Medicare. If this is the case, then your items will not likely be covered through Medicare. With that in mind, it is important to ask questions so that you understand why your doctor is recommending these particular item
If you want vision benefits included in your Medicare coverage, you’ve got to buy it either as a policy separate from your PDP or your Medicare supplement policy (here’s a decent example) or buy a Medicare Advantage plan that includes it.
Many Medicare Advantage plans will offer coverage for vision related benefits, which can include eye exams, as well as coverage for eyeglass frames and lenses and for contact lenses. Medicare Advantage plans are offered through private insurance companies like United Healthcare, Aetna and Humana. The benefits all these plans offer can differ wildly. Use an independent insurance agent to determine the best fit for you.