Eye Health: What Medicare Does and Does Not Cover

Eye care : Checkup of a young woman's eyes

Eye care is something everyone should think about, but very few people do. An increasing number of Americans will have eye problems long before they reach Medicare age. Many adults in their early to mid-40s develop problems seeing things at close distances. The condition, presbyopia, will cause your vision to deteriorate over time. It is the number one eye condition amongst Americans aged 41-60.

If you are over the age of 40 and have one of the conditions below, you’re at greater risk of developing eye problems by the time you’re eligible for Medicare:

  • Diabetes, high blood pressure, or another chronic systemic condition
  • A family history of macular degeneration or glaucoma
  • Any health condition related to anxiety, depression, thyroid, or high cholesterol; certain medications have negative side effects with regards to your vision

What Does Medicare Cover?

Now that you know the importance of eye health, let’s look at what you can expect from Medicare.

Annual Eye Exam

Medicare Part B covers an annual eye exam to search for diabetic retinopathy. You only receive coverage if you are a Medicare beneficiary with diabetes. You pay 20% of the Medicare-approved amount for the doctor’s services, along with your Part B deductible.

Glaucoma Tests

You are eligible for a glaucoma test every 12 months if you have Medicare Part B and are at a high risk of developing the condition. Examples of high-risk patients include those with a family history of the condition, African-Americans aged 50+, Hispanics aged 65+, and patients with diabetes. Again, you pay 20% of the approved amount for the doctor’s services, and the Part B deductible. If the test takes place in a hospital setting, an additional copayment charge applies.

Macular Degeneration

Part B will cover specific diagnostic tests and treatments for eye conditions, including injections using certain drugs. Some Medicare beneficiaries with age-related macular degeneration have coverage. As is the case with the two tests above, you pay 20% of the approved amount for the doctor, and a Part B deductible. You are also responsible for a copayment if the tests take place in a hospital setting.

Other Coverage

In general, Medicare covers eye care services for beneficiaries with chronic eye conditions such as glaucoma or cataracts. You receive coverage for the following:

  • Surgery to help repair/restore the eye’s function because of a chronic eye condition
  • Contact lenses or eyeglasses if you have cataract surgery and receive an intraocular lens; you are also eligible for coverage for a standard pair of contact lenses or eyeglasses if you need them after the procedure; you only receive coverage for customized eyewear in the event it is medically necessary
  • An eye exam to diagnose whether or not you have eye problems; this coverage is available to Medicare beneficiaries suffering from vision problems
  • Part A only covers vision care when the problem is a medical one; for example, if you have a traumatic injury that affects your vision and you go to the hospital
  • Eye prostheses for a damaged eye or if you are missing an eye due to trauma, surgical removal, or a congenital disability; it also covers the resurfacing and polishing of the prostheses twice a year along with one increase or decrease in the size of the prostheses

What Does Medicare Not Cover?

Overall, Medicare Part B’s vision coverage is limited to treatment of specific medical conditions related to the eye, provided by a doctor. It does not cover routine visits or care provided by an optician or optometrist. It also does not cover contact lenses or eyeglasses unless required after surgery.

As a result, your best avenue for vision care coverage is to purchase additional insurance such as Medicare Advantage (Part C). As well as offering the same benefits as Original Medicare as a minimum, the private insurers offering these plans usually include extra benefits such as routine vision and dental care.

Final Words

One of the biggest criticisms of Medicare is its failure to cover vision, hearing, and dental treatment. As it is likely that the current government and future ones will place a tight rein on Medicare expenditure, we don’t expect dental, vision, or hearing coverage to feature as part of the plan.

In other words, if you want vision coverage, you need to go into the marketplace and find a private insurer that offers a good plan for a reasonable price. Your eyesight is incredibly important; don’t take it for granted.

 

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