by Russell Noga | Updated May 30th, 2023
Does Medicare Supplement Cover Eye Exams?
Losing your vision as you age is frustrating. Being unable to read the newspaper and straining to watch the TV reduce your quality of life. Eye exams, contact lenses, and eyeglasses are expensive, and not all seniors can afford to add them to their annual healthcare expenses.
Original Medicare Parts A & B assist seniors in America with reducing their healthcare expenses in their senior years, and Medicare supplement insurance further reduces these costs.
Let’s look at how Medicare works with eye exams and coverage.
However, there are workarounds where you can get coverage or at least deeply discounted rates on eye exams and eyewear to help you manage your vision as you age. This post unpacks everything you need to know about the topic.
Original Medicare and Eye Exams
Original Medicare doesn’t cover routine eye exams. However, it does cover checkups for some vision and eye-related conditions. Medicare pay for eye tests if you’re diagnosed with or at risk of developing glaucoma, diabetes, or macular degeneration.
Original Medicare offers annual glaucoma eye tests for beneficiaries with the following risk profile.
- A family history of diabetes or glaucoma.
- African Americans (age 50+).
- Hispanics (age 65+).
Medicare allows annual eye exams for diabetic beneficiaries at risk of developing diabetic retinopathy.
Medicare covers diagnostic eye exams for age-related macular degeneration if your doctor diagnoses or suspects the disease.
Glasses for Cataract Patients
Medicare covers vision care for beneficiaries receiving prosthetic eyes or those undergoing cataract surgery. Medicare limits the use of these benefits.
Ensure you follow the Medicare guidelines to get optimal coverage. Medicare covers one pair of glasses or contact lenses after undergoing cataract surgery, provided you use a supplier in their network.
Medicare covers an artificial or prosthetic eye and follow-up resurfacing and polishing twice yearly. The doctor must order your prosthetic, and you must use a supplier in the Medicare network.
Refraction Eye Exam Medicare Coverage
Refraction eye exams are comprehensive assessments performed by eye care professionals to determine an individual’s prescription for corrective lenses, such as eyeglasses or contact lenses. These exams involve the use of various diagnostic techniques, including examining the eye’s ability to focus light accurately.
Medicare Coverage and Refraction Eye Exams
Original Medicare, comprising Part A (hospital insurance) and Part B (medical insurance), provides coverage for many essential healthcare services. However, when it comes to refraction eye exams, Medicare coverage is limited. Under Original Medicare, routine eye exams, including refraction, are generally not covered, except for specific medical conditions such as cataracts or diabetes-related eye diseases.
Medicare Part B does cover some eye-related services, including diagnostic tests, such as those used to diagnose and treat diseases like glaucoma. Additionally, Part B covers certain preventive services, like screening for age-related macular degeneration. However, it’s crucial to note that refraction eye exams, which are necessary for prescribing corrective lenses, fall outside the scope of Medicare coverage.
Medicare Supplement Plans: Bridging the Gap
To address the limitations of Original Medicare, individuals can consider enrolling in a Medicare Supplement (Medigap) plan. Medicare Supplement plans, offered by private insurance companies, work alongside Original Medicare to provide additional coverage for out-of-pocket expenses.
While Medicare Supplement plans do not typically cover refraction eye exams directly, they can help with the costs associated with other eye care services. For example, some Medigap plans may cover the coinsurance or copayments related to medically necessary eye surgeries or treatments, such as cataract removal.
Furthermore, Medicare Supplement plans can also offer coverage for other important healthcare services, such as prescription drugs, which may include eye medications prescribed by an eye care professional. These plans provide peace of mind by filling the coverage gaps left by Original Medicare, ensuring individuals have access to comprehensive eye care services.
Choosing the Right Medicare Supplement Plan
It’s important to understand that not all Medicare Supplement plans offer the same benefits. There are ten standardized Medigap plans, labeled with letters from A to N. Each plan offers a different combination of coverage and benefits. For instance, some plans may include coverage for foreign travel emergencies, while others may provide coverage for Part B excess charges.
When considering a Medicare Supplement plan, it is crucial to carefully review the benefits and coverage provided by each plan. Comparing the costs, deductibles, copayments, and other factors can help individuals select the plan that best suits their specific needs and budget.
Why a Supplement Makes Sense
While Original Medicare does not typically cover refraction eye exams, enrolling in a Medicare Supplement plan can offer additional coverage and help individuals manage their eye care expenses. Medicare Supplement plans play a crucial role in bridging the gap left by Original Medicare, providing peace of mind and access to comprehensive eye care services. By understanding the coverage options available, individuals can make informed decisions to ensure their eye health remains a priority throughout their Medicare journey.
Medicare Advantage Plans and Eye Exams
Some Medicare Advantage plans may offer additional benefits such as vision care. Not all Medicare Advantage plans are the same, and each one has different additional benefits above Original Medicare.
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What Does Medicare Pay for Your Vision Care?
Original Medicare Part B covers 80% of pre-approved costs for the above vision complications and treatment plans. If you only have Parts A & B, you must pay the remaining 20% of the out-of-pocket expenses not covered by Medicare.
For instance, if a glaucoma test costs $100, you must pay the remaining $20 not covered by Medicare after meeting your Part B deductible of $226. Vision care received in outpatient hospitals requires a separate copay for the hospital fee.
The copay varies but doesn’t exceed the Medicare Part A deductible of $1,600 for 2023. Participating providers and suppliers in the Medicare network accept payment at lower rates than their standard consultation fees.
When using participating providers, the amount owed is lower than standard rates, saving you money on your treatment.
Does Medicare Advantage Offer Vision Coverage?
MA plans cover some costs relating to vision care. Here’s a quick overview.
- 98% of MA plans offer additional vision benefits.
- Over 50% of MA plans require pre-authorization before approval.
- Most MA plans have a coverage limit of $100 to $200 annually.
- Eyewear is covered once a year or every other year.
Medicare Advantage plans usually provide beneficiaries with vision benefits similar to Original Medicare Part B. These services include eye exams and eyewear after cataract surgery, vision care relating to diabetes treatments and care plans, and patients suffering from Macular degeneration or glaucoma. It also covers eye prosthetics.
Some Medicare Advantage policies add extra benefits, such as eye exams and eyewear, over what Original Medicare covers. Coverage and costs for these plans vary, and with over 300 MA plans available, reviewing your policy before signing up is a good idea.
Medigap Plan Coverage
Medigap plans are available in ten options, each offering a different level of coverage. All Medigap plans to provide the following benefits.
- Part A coinsurance and hospital costs for up to 365 days after using up Medicare benefits.
- Part A hospice care coinsurance or copayment.
- Part B coinsurance or copayment.
- Blood transfusion costs for the first three pints of blood.
Plans F, G, and N offer additional Medicare Parts A & B benefits.
- Part A deductible.
- Part B excess charges (Plan N doesn’t cover these charges).
- Skilled nursing facility care coinsurance.
- 80% of emergency healthcare costs when traveling outside the US for 60 days. ($250 deductible and $50,000 maximum apply).
- Unlimited coverage for all out-of-pocket costs.
Medicare Must Pay First
If Medicare covers the cost of vision treatments, Medigap plans usually pay the balance of 20% of the remaining out-of-pocket costs, depending on your policy type. These plans partially or fully cover the costs of the deductible and the 20% coinsurance responsibility.
Plans F & G will cover the cost completely (Plan F is only available to seniors eligible for Medicare before January 1, 2020). Plan K pays 50%, and Plan L pays 75% of the coinsurance cost. Plan N pays the remaining 20% coinsurance but requires a copayment.
If Medicare rejects your claim for vision services, Medigap will not cover anything, leaving you responsible for settling the bill. For example, if Medicare approves a charge of $1,000 for your vision services, Medicare would pay 80% ($800).
After meeting the Part B deductible (Plan F covers the Part B deductible in full*), you must pay the remaining 20% ($200) out-of-pocket. However, if you have Plan G, it fully covers this coinsurance cost. The 50% coinsurance with Plan K would leave you $100 to pay, and the 75% coverage from Plan L leaves you with a $50 payment. Plan N covers everything but requires a $20 copayment.
Some Medigap insurers offer additional plans covering the costs of vision, dental, and hearing services for a small monthly fee of $20 to $40. Others may offer discounted rates of up to 60% on eye exams and eyewear.
Let Our Team Find You a Medigap Plan with Vision Coverage
If you want more information on Medigap plans, reach out to our team at 1-888-891-0229. Our Medigap experts are available for a free consultation and quote on any Medigap plan.
If you want a fully licensed Medigap agent to call you back, leave your contact details on our form, and we’ll get someone to call you back to discuss your healthcare requirements.
Russell Noga is the CEO of Medisupps.com, an online Medicare Agency and resource center helping Medicare beneficiaries learn about Medicare, Medigap and Part D drug plans, and Medicare Advantage plans since 2009. Russell is licensed in all 50 states and has been featured as a keynote speaker, and author of several publications, along with hosting the very popular Medisupps.com Youtube channel.