Medicare & Vision Coverage
The original form of the Medicare, Part A and Part B, are the foundation of standard Medicare benefits from the government. While broad hospitalization and medical benefits are included in Part A and Part B coverage, not every healthcare service is covered. Traditional vision coverage is not among the benefits of Medicare Parts A and B.
The absence of vision benefits within traditional Medicare coverage does not mean a Medicare enrollee cannot obtain some form of vision insurance coverage. HealthPocket’s research on 2014 Medicare Advantage plans found that nearly all Medicare Advantage plans in the U.S. (94%) included some form of vision benefits. Since vision benefits are not standardized, the details of these vision benefits varied among plans.
Another insurance option that seniors can investigate is a stand-alone vision plan. The phrase “stand-alone” is used to indicate that the vision coverage is not a rider within a larger insurance plan.
As mentioned earlier, traditional Medicare Parts A and B do not provide vision benefits in most cases. This means that regular eye exams related to eyeglass prescriptions, and the associated glasses or contacts, are not normally covered by Medicare. There are some exceptions such as for people who undergo cataract surgery and require corrective glasses or contacts related to an implanted intraocular lens.
However, insurance coverage for vision issues can be very important to the senior enrollees within the Medicare program. Over 150 million Americans of all ages utilize corrective eyewear (glasses, contacts, etc.). Seniors, in particular, may face a series of eye issues that are more prevalent among the aged:
- Cataracts – A defect in the lens of the eye that negatively affects vision
- Dry eye – The medical condition where an inadequate supply of tears is produced to lubricate the eye and facilitate unobstructed vision
- Diabetic retinopathy – A condition where the vessels supplying the retina with blood are damaged and can lead to blindness
- Glaucoma – An eye disease affecting the optic nerve and can lead to blindness
Does Medicare Pay for Glasses?
Original Medicare does not pay for eyeglasses in most situations. However, there are medical circumstances (e.g. an eye injury) where Medicare will pay for a pair of glasses or contact lenses. The Centers for Medicare & Medicaid Services (CMS) states that for Medicare to pay for vision services, the services must satisfy three basic requirements:
- They must fall within a statutorily-defined benefit category
- They must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body part
- The item or service must not be excluded from coverage
When Medicare does pay for eyeglasses or contact lenses, the following conditions apply:
- You pay 20% of the Medicare-approved amount for one pair of eyeglasses (or one set of contact lenses) after each cataract surgery employing an intraocular lens
- The Medicare program will only pay for contact lenses or eyeglasses from an eyewear supplier enrolled in Medicare
- You pay any additional costs for upgraded eyeglass frames
- You pay 100% for non-covered vision services, including most eyeglasses or contact lenses
- The Medicare Part B deductible applies
As mentioned earlier, Medicare enrollees seeking vision coverage have several options:
- Medicare Advantage plan with vision benefits
- Stand-alone vision insurance
Before enrolling in any vision insurance, confirm the coverage details regarding:
- Routine eye exams
- Discounts on eyeglasses (both lenses and frames)
- How frequently new eyeglasses can be obtained
- Discounts on contacts
- How frequently new eyeglasses can be obtained
Regular eye exams are recommended for seniors. Aside from documenting any changes in vision, eye exams can also detect other issues related to health. Medicare does not pay for routine eye exams related to glasses. However, Medicare does pay for eye exams related to:
- An annual eye exam to screen for diabetic retinopathy (applies to diabetics)
- Glaucoma tests for people at higher risk for glaucoma
- Macular degeneration tests for people with age-related macular degeneration
Cataracts and Cataract Surgery
The American Academy of Ophthalmology’s review of vision statistics indicate that by age 80 over half of Americans have at least one cataract. Cataracts are often treated by surgery. Medicare Part A does cover medically-necesary cataract surgery and related healthcare. The average cost (without insurance) for cataracts ranges from $3,000 to nearly $5,000. However, for Medicare beneficiaries there is a Medicare rate and normally the patient would pay the normal Medicare deductibles and co-payments. The specifics of these out-of-pocket costs partially depend on whether the procedure is performed as an in-patient or out-patient surgery.
Medicare Eye Doctors, Ophthalmologists, and Optometrists
Before enrolling in an insurance plan for the purpose of obtaining vision coverage, you should ask the following questions:
- Does my eye doctor, optometrist, or ophthalmologist accept this insurance?
- How many routine visits to vision professionals are covered each year?
- How much will I pay out-of-pocket to visit a vision professional within the insurance plan’s network of providers?