Eye Care Costs Covered by Medicare

By Nancy DellaVecchia
eMedicareSupplements Contributor

Most Routine Eye Care Is Not Covered By Medicare

Medicare and Medigap insurance plans do not cover routine eye examinations or the cost of eyeglasses. However, because Medicare does cover treatment of issues such as glaucoma, blepharitis and dry eye syndrome, some costs can be covered if you suffer from a serious eye condition.

Eye Exam Coverage

If you have been diagnosed with cataracts and get a routine eye exam where you receive a prescription for new glasses, Medicare will pay for the eye exam, but not the part of the exam known as refraction, when the optometrist tests your visual acuity.

When billing, the doctor will use Medicare codes that distinguish between the exam and the refraction. For example, if the total cost of an exam for a person with cataracts is $150, and $25 is charged for refraction, Medicare will pay 80 percent of $125 because they do not cover the cost of refraction. Since cataracts are a qualifying medical condition, the cost of the general eye examination is covered.

Coverage for Eyeglasses

As a rule, there is no coverage for glasses or contact lenses, but seniors who undergo cataract surgery are entitled to coverage for basic frames and lenses following surgery. Basic lenses do not include bifocals, trifocals or progressive lenses. If a senior has separate cataract surgeries for each eye and there is a fairly long time lapse between the two surgeries, Medicare may pay for a second pair of glasses.

Indigent seniors who qualify for Medicaid may be eligible for yearly eye exams and basic glasses under the Medicaid program even though Medicare does not provide coverage. Medicaid vision coverage for adults is decided by the state of residence. Some states only provide vision care for children under 18, while some provide vision care for children under 18 and adults over 65.

Medicare Advantage Eye Coverage

Medicare Advantage plans are private medical insurance policies that are primarily paid for by Medicare, although some plans may require a partial premium payment from the insured person. Many Advantage policies offer additional coverage that may include dental and vision care. Seniors with Medicare Advantage plans should check with their insurer to see if yearly eye exams are covered.

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