Medicare Part B covers some eye care, but not routine eye exams

Medicare Part B covers eye care related to disease or injury — such as treatment for glaucoma, cataracts, or diabetic retinopathy — but it does not cover routine eye exams done to check your vision or update your glasses prescription. The distinction matters because it determines what you pay and which providers you can see.

If you have a medical eye condition, Part B will cover the exam to diagnose or monitor it, along with treatment. If you want an exam purely to see whether you need new glasses, that exam is your responsibility. Many people confuse the two because the same doctor performs both kinds of exams.

Key Takeaways

  • Medicare Part B covers eye exams and treatment when they are for a diagnosed medical condition like glaucoma, cataracts, macular degeneration, or diabetic eye disease.
  • Medicare Part B does not cover routine eye exams performed to check your vision or update your glasses or contact lens prescription.
  • You pay 20 percent of the Medicare-approved amount for covered eye exams and treatments after you meet your Part B deductible.
  • Routine eye exams may be covered under a Medicare Advantage plan's vision benefit, so check your plan documents or call the plan directly.
  • You can see any ophthalmologist or optometrist who accepts Medicare; you do not need a referral from your primary care doctor.

What Part B covers: eye exams for medical conditions

Part B covers an eye exam when an ophthalmologist or optometrist performs it to diagnose, monitor, or treat a disease of the eye. Common covered conditions include glaucoma, cataracts, age-related macular degeneration, diabetic retinopathy, and dry eye syndrome. The exam itself is covered, along with any diagnostic tests the doctor orders — such as visual field testing, optical coherence tomography (OCT), or tonometry to measure eye pressure.

If the exam leads to treatment, Part B also covers that treatment. For example, if you are diagnosed with glaucoma, Part B covers the eye drops or laser treatment. If you have a cataract, Part B covers the surgery and the intraocular lens implant. You will pay 20 percent of the Medicare-approved amount after you have met your Part B deductible for the year.

The key requirement is that the exam must be medically necessary — meaning the doctor has a clinical reason to perform it, not just a desire to update your prescription. If you go to an eye doctor for a routine checkup and the doctor finds a condition during that visit, the portion of the exam related to diagnosing that condition is covered, but the routine vision screening part is not.

What Part B does not cover: routine vision exams and glasses

Medicare Part B does not cover routine eye exams — the kind you get to check whether your vision has changed or to update your glasses or contact lens prescription. It also does not cover eyeglasses, contact lenses, or the fitting of either. This applies even if you have never had an eye exam on Medicare and have not had your vision checked in years.

The only exception is one pair of eyeglasses or contact lenses after cataract surgery. If you have cataract surgery covered by Part B, Medicare will pay for one pair of glasses or contacts and the fitting, but only in the when ready period after surgery while your eye is healing. After that, routine vision correction is your responsibility.

How to know whether your eye exam will be covered

Before you schedule an eye exam, tell the office that you have Medicare and ask whether the visit will be for a specific medical condition or for a routine checkup. If you already know you have a condition like glaucoma or diabetes affecting your eyes, the exam to monitor that condition is covered. If you are going in for a general checkup with no known condition, the exam is not covered.

If you are unsure, you can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) and describe your situation. You can also ask the eye doctor's office to contact Medicare to verify coverage before your visit. Some offices will do this at no charge; others may ask you to pay for the verification call.

Keep in mind that even if an exam is covered, you will still owe your Part B deductible and 20 percent coinsurance. If you have a Medigap or Medicare Advantage plan, your plan may cover some or all of that cost.

Medicare Advantage plans and routine eye coverage

Many Medicare Advantage plans (Part C) include a vision benefit that covers routine eye exams, glasses, or contact lenses. The coverage varies widely — some plans cover one routine exam per year, others cover two, and some include a dollar allowance toward glasses or contacts. A few plans cover neither routine exams nor glasses.

To find out what your Medicare Advantage plan covers for vision, check the plan's Summary of Benefits document, which you received when you enrolled. You can also call the plan's customer service number, usually printed on your insurance card. If you are still in the annual enrollment period and your current plan does not cover routine eye exams, you can switch to a plan that does.

If you have Original Medicare (Part A and Part B) without a Medicare Advantage plan, you do not have a routine vision benefit through Medicare itself. You would need to pay out of pocket for routine exams and glasses, or purchase a separate vision insurance plan.

What you pay for covered eye care

For eye exams and treatments covered by Part B, you pay 20 percent of the Medicare-approved amount after you meet your Part B deductible. The deductible is the same for all Part B services combined — once you have paid it, you do not pay it again that year, even if you see multiple doctors.

The actual amount you owe depends on what the doctor charges and what Medicare approves. Medicare sets an approved amount for each type of exam and procedure. If the doctor charges more than that amount, you are responsible only for the 20 percent of the approved amount, not the difference. This is called "accepting assignment."

Most eye doctors who treat Medicare patients accept assignment, meaning they agree to charge only the Medicare-approved amount. Before your visit, you can ask the office whether they accept assignment. If they do not, you could owe more than 20 percent.

Where to find an eye doctor who accepts Medicare

You can see any ophthalmologist or optometrist who accepts Medicare. You do not need a referral from your primary care doctor, and you do not need to stay within a network (unless you have a Medicare Advantage plan with network restrictions).

To find doctors near you, use the Medicare Provider Search tool at Medicare.gov. Enter your zip code and search for "ophthalmology" or "optometry." The search results will show which doctors accept Medicare assignment. You can also call your local hospital or ask your primary care doctor for a referral to an eye doctor who accepts Medicare.

When you call to schedule an appointment, confirm that the doctor accepts Medicare and that the visit will be for a covered service. Bring your Medicare card to your appointment.

Frequently Asked Questions

Will Medicare cover an eye exam if I have diabetes?

Yes, if the exam is to check for diabetic retinopathy or other eye complications from diabetes. That exam is covered as a medical service. However, if you go in for a routine vision check and the doctor happens to notice you have diabetes, only the portion of the exam related to diagnosing the diabetes complication is covered, not the routine vision screening part.

Do I need a referral to see an eye doctor on Medicare?

No. You can see any ophthalmologist or optometrist who accepts Medicare without a referral from your primary care doctor. If you have a Medicare Advantage plan, check your plan documents to see whether you need a referral or whether there are network restrictions.

What if I need new glasses after a covered eye exam?

Medicare Part B does not cover the glasses themselves or the cost of the exam to determine your prescription. If the exam was covered because of a medical condition, you would need to pay out of pocket for glasses. The only exception is one pair of glasses after cataract surgery.

Can I use my vision insurance along with Medicare?

Yes. If you have a separate vision insurance plan, you can use it for routine exams and glasses. Medicare and your vision plan will coordinate benefits. Tell your eye doctor's office that you have both Medicare and vision insurance so they can bill correctly.

Does Medicare cover contact lenses?

Medicare Part B does not cover contact lenses or the fitting of them. The only exception is one pair of contact lenses after cataract surgery. If you have a Medicare Advantage plan with a vision benefit, check your plan documents to see whether it covers contacts.