Does Medicare Include Vision Benefits?

Original Medicare provides coverage for many of the services you may need, including hospital insurance for emergencies or life-threatening situations, along with routine visits to a doctor’s office. But unfortunately, Original Medicare does not offer vision benefits.

Generally, Medicare will cover some limited eye care and vision expenses that may be associated with a larger health problem that affects your sight, such as diabetes, macular degeneration or a traumatic injury. For select Medicare recipients, yearly glaucoma screenings will also be covered. Still, the cost of regular vision needs, like eye exams and corrective eyewear, will be your financial responsibility. In most cases, the only route to having coverage for non-life threatening optical needs is through additional benefits provided by a Medicare Advantage plan or a private health insurance policy.

What Medicare Excludes From Vision Care

Like other insurance providers, Medicare considers vision benefits to be additional coverage that you can add on through a private insurer or Medicare Advantage plan. With Original Medicare, there are no vision benefits and 100% of the cost for routine eye care and screenings will fall on you. For example, Medicare does not cover any of these services:

• Yearly eye exams by an optometrist
• Glaucoma and other eye testing for people who do not have diabetes
• Corrective eyeglasses or contacts

In most cases, another form of insurance such as Medicare Advantage or a private insurance plan can provide vision benefits if you need these services or items. If you are interested in exploring your options, PolicyZip’s Medicare Specialists can help. Call (844) 205-7510 to speak with a specialist or fill out the form below.

Special Exceptions for Beneficiaries with Diabetes and Other Conditions

While Medicare overall has a “no-vision care” rule, it does provide some partial coverage for necessary eye care service for some beneficiaries. Generally speaking, these are individuals who have other health conditions that impact their eyesight, such as diabetes or macular degeneration. The difference here is that Medicare determines eye care for these individuals to be medically necessary, compared to routine.

Medicare Part B will cover a year eye exam for diabetic retinopathy — damage to the blood vessels at back of the eye due to diabetes — and the cost of testing. Anyone who has Part B coverage and diabetes diagnosed by a doctor qualifies for coverage, but will still be responsible for the Part B deductible and 20% of the doctor’s bill. Some doctor’s offices also require a copay.

Recipients who are at high risk for glaucoma (often people with diabetes) are granted coverage for one glaucoma test every 12 months. Medicare considers you at high-risk if:

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

If you qualify for glaucoma testing, you will still need to pay the Medicare Part B deductible and 20% of the cost. You may also pay a copay at some doctor’s offices.

Individuals with macular degeneration, an incurable sight condition where the retina deteriorates and causes vision loss, also qualify for some vision benefits. Medicare will cover some diagnostic testing and treatments for macular degeneration, as well as some of the injectable medications your condition may require. Part B enrollees with age-related macular degeneration diagnosed by a doctor can use this benefit, but will be responsible for Part B premiums and 20% of the cost.

Medicare also provides coverage for diagnostic eye exams in cases where a chronic health condition could potentially impact your sight. Here, Medicare will help pay the cost of testing and examinations, even if it turns out that your eyes are healthy and vision is fine.

Traumatic Eye Injuries, Vision Emergencies and Major Surgeries

While Original Medicare does not cover routine eye care, Medicare Part A benefits can be used in emergency health situations that impact your eyesight. This often occurs when a patient has had a traumatic eye injury or requires major eye treatment, such as cataract surgery.  In these cases, care to repair an eye-related emergency can be covered by your Part A hospital insurance so long as you are admitted to a hospital and receive treatment there. This means that even if Medicare does not cover routine eye exams and glasses, you can seek treatment at a hospital for a serious eye injury and receive some level of coverage — there is no reason to go without medical attention.

Medicare Part B will also extend vision benefits to individuals who require eye prostheses for a variety of reasons, including birth defects, surgical removal or damage. This applies to patients who have lost an eye or if the eye has shrunk in size. For these patients, Medicare will cover 80% of the initial prosthetic cost, as well as reshaping and repair.

If you suffer from cataracts, Medicare will help with the cost of corrective surgery and some of the corrective devices you need afterwards. For more information on Medicare benefits for cataract patients, visit our Medicare and Cataracts Explained page.

Finding Vision Coverage

Since Original Medicare does not offer standard vision coverage for everyday eye needs, you may want to consider other kinds of insurance that can fill this gap. Many Medicare enrollees who do not require corrective eyeglasses or contacts can choose to remain with the Original Medicare plan and just pay out-of-pocket for annual eye examinations. But the cost of glasses, diagnostic testing and regular exams can add up for beneficiaries who already have poor vision. In this case, a Medicare Advantage plan provided by a private insurance company can help you with vision care costs, meanwhile receiving at least the same level of coverage as Original Medicare — if not more, with additional benefits such as dental coverage. Every Medicare Advantage provider offers a selection of plans to choose from and the search can be overwhelming. Consider speaking with a PolicyZip Medicare Specialists to weigh your options and locate the best plan with vision benefits at an affordable price.