Medicare covers one diabetic eye exam per year at no cost to you
Yes, Medicare Part B covers a yearly dilated eye exam to check for diabetic retinopathy — damage to the blood vessels in your retina caused by diabetes. You pay nothing for the exam itself if your eye doctor accepts Medicare. The exam must be performed by an ophthalmologist or optometrist, and it includes dilating your pupils so the doctor can see the back of your eye clearly.
This coverage applies whether you have Type 1 or Type 2 diabetes and whether your diabetes is well-controlled or not. The goal is to catch eye damage early, before it affects your vision. If you have already been diagnosed with diabetic retinopathy, you may be covered for more frequent exams — your doctor will determine how often you need to be seen.
Key Takeaways
- Medicare Part B covers one dilated eye exam per year for people with diabetes, with no copay or coinsurance if your eye doctor accepts Medicare.
- The exam must include dilation of your pupils and must be performed by an ophthalmologist or optometrist to be covered.
- If you have diabetic retinopathy or other eye complications, your doctor may recommend more frequent exams, which Medicare will also cover.
- You are responsible for any charges if you see an eye doctor who does not accept Medicare, unless you have a Medigap or Medicare Advantage plan that covers out-of-network care.
- Glasses, contact lenses, and other vision correction devices are not covered by this benefit.
How to make sure your exam is covered
Before you schedule your exam, confirm that your eye doctor accepts Medicare assignment. This means they have agreed to accept Medicare's payment as full payment for the service. You can search for in-network eye doctors on Medicare.gov or call your eye doctor's office directly and ask if they accept Medicare.
When you arrive for your appointment, bring your Medicare card. Tell the staff that you are there for a diabetic eye exam. If your doctor performs the exam and includes dilation, Medicare will cover it. If the doctor does not dilate your eyes, the exam may not be covered under this benefit.
If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your coverage may differ. Some Medicare Advantage plans cover the same benefit; others may have different rules or require you to use in-network providers. Check your plan documents or call your plan's customer service to confirm what is covered before your visit.
What is not covered under this benefit
Medicare does not cover glasses, contact lenses, or other vision correction devices through this diabetic eye exam benefit. If you need new glasses or contacts after your exam, you will pay for them out of pocket. Some Medicare Advantage plans offer vision coverage that includes glasses or contacts, but Original Medicare does not.
The exam also does not cover treatment for eye conditions unrelated to diabetes — for example, a cataract evaluation or glaucoma screening. If your eye doctor identifies a separate eye problem during your diabetic exam, that treatment would be covered under different Medicare rules, but the initial screening for that condition may not be.
What happens if you have diabetic retinopathy
If your eye doctor finds signs of diabetic retinopathy during your exam, Medicare will cover additional exams more frequently than once per year. The number of exams covered depends on the severity of the retinopathy and what your doctor recommends. Your doctor will document the diagnosis in your medical record, and Medicare will honor the recommendation for more frequent monitoring.
Treatment for diabetic retinopathy — such as laser surgery, injections into the eye, or vitrectomy — is covered by Medicare Part B when medically necessary. These are separate from the screening exam and are covered under different benefit rules. Your eye doctor's office can help you understand what your out-of-pocket costs will be for any treatment recommended.
If you do not have Medicare yet
If you have diabetes but are not yet on Medicare, you may still be covered for diabetic eye exams through your current health insurance. Check your plan documents or call your insurance company to see what eye care is included. Once you turn 65 and enroll in Medicare, the yearly diabetic eye exam benefit becomes available to you automatically if you have Part B.
If you are under 65 and have diabetes, you may also be covered for eye exams through Medicaid, depending on your state and income. Contact your state Medicaid office to learn what is available in your area.
Costs if your eye doctor does not accept Medicare
If you see an eye doctor who does not accept Medicare assignment, you may have to pay the full cost of the exam upfront and then submit a claim to Medicare yourself. Medicare will reimburse you for a portion of the cost, but you will likely pay more out of pocket than if you had seen an in-network provider.
The amount Medicare reimburses varies by location and the specific exam code used. If you have a Medigap (supplemental insurance) plan, it may cover some or all of the remaining balance after Medicare pays. If you have a Medicare Advantage plan, check your plan's rules about out-of-network providers — some plans do not cover out-of-network eye care at all.
Keeping track of your yearly exam
Medicare does not send reminders for your yearly diabetic eye exam, so it is up to you to schedule it. A good time to schedule is around the same time each year — for example, on your birthday or at the start of each calendar year. This makes it easier to remember and ensures you do not miss the benefit.
If you see your primary care doctor regularly, ask them to remind you when it is time for your eye exam. Some primary care offices keep track of preventive care visits and will send a reminder when you are due. You can also set a phone reminder or calendar alert on your own.
Frequently Asked Questions
Do I need a referral from my doctor to get a diabetic eye exam covered?
No, you do not need a referral. You can schedule directly with an ophthalmologist or optometrist who accepts Medicare. However, if your primary care doctor has recommended an eye exam or suspects diabetic eye disease, it is helpful to mention that when you call to schedule.
What if I have both Type 1 and Type 2 diabetes?
This is not possible — you have one type of diabetes. However, if you have either type, you are covered for the yearly diabetic eye exam. The coverage is the same regardless of which type you have.
Can I get more than one exam per year if I want to?
You can schedule as many exams as you want, but Medicare will only cover one per year unless your eye doctor documents that you have diabetic retinopathy or another eye condition that requires more frequent monitoring. Any additional exams beyond what Medicare covers will be your responsibility to pay for.
Does this benefit cover a regular eye exam for glasses?
No. The diabetic eye exam is specifically for screening and monitoring diabetes-related eye disease. If you also need an exam to update your glasses prescription, that is a separate service and is not covered by Medicare.
What if my eye doctor says I do not have diabetes anymore?
Once you have been diagnosed with diabetes, you remain covered for the yearly diabetic eye exam even if your blood sugar is well-controlled or your doctor says your diabetes is in remission. The benefit is available to you for life as long as you have Medicare Part B.