Medicare covers one eye exam every 12 months if you have diabetes or age-related macular degeneration, and one pair of eyeglasses or contact lenses after cataract surgery. For routine eye exams without these conditions, Original Medicare does not pay.
The coverage depends on why you need the exam. If you have diabetes or macular degeneration, Medicare Part B covers a dilated eye exam once per year to check for disease. If you have had cataract surgery, Medicare covers one pair of eyeglasses or contact lenses (your choice, not both) within a set time after the surgery. If you straightforward want a routine eye exam to check your vision or update your prescription, Original Medicare does not cover it.
Medicare Advantage plans (Part C) may cover routine eye exams and eyeglasses differently than Original Medicare does. Some plans cover one or two routine exams per year and may pay toward frames and lenses. You need to check your specific plan's coverage, because it varies widely.
Key Takeaways
- Medicare Part B covers one dilated eye exam per year only if you have diabetes or age-related macular degeneration.
- After cataract surgery, Medicare covers one pair of eyeglasses or contact lenses within a specific window, usually a few weeks after surgery.
- Routine eye exams for vision changes or new prescriptions are not covered by Original Medicare.
- Medicare Advantage plans may cover routine exams and eyeglasses, but coverage varies by plan and you must check your documents.
- You pay the full cost of routine eye exams and most eyeglasses out of pocket unless your plan covers them.
Eye Exams for Diabetes and Macular Degeneration
If you have been diagnosed with diabetes, Medicare Part B covers a dilated eye exam once every 12 months. The exam must be performed by an ophthalmologist or optometrist and must include a dilated retinal exam to look for diabetic retinopathy. You pay 20 percent of the Medicare-approved amount after you meet your Part B deductible; Medicare pays 80 percent.
If you have age-related macular degeneration (AMD), Medicare covers one dilated eye exam per year for the same reason — to monitor the disease and catch changes early. The same cost-sharing applies: you pay 20 percent after your deductible.
These exams are considered medically necessary because both conditions can cause vision loss if not monitored. If you have both diabetes and AMD, you still receive only one covered exam per 12-month period, not two.
Eyeglasses and Contact Lenses After Cataract Surgery
After you have cataract surgery, Medicare covers one pair of eyeglasses or contact lenses to correct your vision following the procedure. You must choose one or the other — Medicare does not pay for both. The coverage includes frames and lenses, or the contact lenses themselves.
The glasses or lenses must be ordered within a set time after surgery, usually within a few weeks. Your surgeon's office will tell you the exact window. You will need a prescription from your eye doctor and a referral from your surgeon. Medicare pays 80 percent of the approved amount after your Part B deductible; you pay 20 percent.
If you need a second pair of glasses or if your prescription changes significantly after that initial pair, Medicare does not cover the cost. You would pay out of pocket or use a vision discount plan if you have one.
What Original Medicare Does Not Cover
Original Medicare does not cover routine eye exams if you do not have diabetes, macular degeneration, or a recent cataract surgery. This means exams to check your vision, update your prescription for reading glasses or distance glasses, or screen for common eye conditions like glaucoma or cataracts are your responsibility.
Medicare also does not cover eyeglasses or contact lenses for routine vision correction. Frames, lenses, and contact solutions are not covered unless they follow cataract surgery. Bifocals, progressive lenses, and special coatings are also not covered.
Some people assume that because Medicare covers so much health care, it must cover eye care. It does not. Many seniors pay for routine eye exams out of pocket or through a vision discount plan, which can reduce the cost by 10 to 40 percent depending on the provider and your location.
Vision Coverage Through Medicare Advantage Plans
Medicare Advantage plans are required to cover everything Original Medicare covers, including the diabetes and macular degeneration exams and post-cataract eyeglasses. Many Advantage plans also add routine vision coverage as an extra benefit.
Some Medicare Advantage plans cover one or two routine eye exams per year at no cost or a small copay. Some cover eyeglasses or contact lenses, either fully or with a dollar limit (for example, $150 toward frames and lenses). A few plans cover both exams and eyeglasses generously; others cover neither.
You can find out what your plan covers by calling the plan's customer service number (on your insurance card) or by reviewing your plan's Summary of Benefits and Coverage document, which you received when you enrolled. If you are thinking about switching plans during the annual enrollment period, vision coverage is worth comparing if you need regular eye care.
How to Find an Eye Doctor Who Accepts Medicare
If you have a covered exam coming up — for diabetes, macular degeneration, or post-cataract care — you can search for an in-network provider on Medicare.gov. Go to the "Care Providers" section and search by your location and specialty (ophthalmology or optometry).
You can also call your local Medicare office or your plan (if you are in a Medicare Advantage plan) to ask for a list of eye doctors in your area. Many eye doctors accept Medicare for covered services but may charge you out of pocket for routine exams.
Before you schedule, confirm with the office that they accept Medicare and that they perform the specific type of exam you need. For example, if you have diabetes, make sure they do dilated retinal exams. If you are scheduling post-cataract glasses, confirm they can submit the claim to Medicare.
What to Bring to Your Eye Exam
Bring your Medicare card and any other insurance card you have. Bring a list of all medications you are taking, because some can affect your eyes. If you are having a covered exam for diabetes or macular degeneration, bring any previous eye exam results if you have them.
If you are scheduling eyeglasses after cataract surgery, bring your surgery paperwork or the name and phone number of the surgeon's office. The eye doctor will need to confirm the timing and get details about your surgery.
If you are paying out of pocket for a routine exam, ask the office in advance what the cost will be. Some offices charge $75 to $150 for a routine exam without insurance.
Frequently Asked Questions
Does Medicare cover eye exams for glaucoma screening?
No. Original Medicare does not cover routine eye exams for glaucoma screening or any other routine eye condition. If you have glaucoma that has already been diagnosed, Medicare covers exams related to managing that condition, but the initial screening is not covered. You would need to pay out of pocket or use a vision discount plan.
Can I get a routine eye exam covered if my doctor says it is medically necessary?
Not through Original Medicare. Medicare has a specific list of covered eye exams: diabetes monitoring, macular degeneration monitoring, and post-cataract care. A doctor's note saying an exam is medically necessary does not add to that list. Medicare Advantage plans may have different rules, so check your plan.
If I have both Medicare and Medicaid, does Medicaid cover eye exams?
Medicaid rules vary by state. Some states cover routine eye exams and eyeglasses through Medicaid; others do not. Contact your state Medicaid office or your Medicaid caseworker to find out what vision services your state covers.
What if I need new glasses but my prescription changed since my cataract surgery?
Medicare covers one pair of glasses within a few weeks after surgery. If your prescription changes after that window closes, the new glasses are not covered. You would pay out of pocket. Some vision discount plans offer discounts on updated prescriptions if you need them within a year of surgery.
Do I need a referral from my primary care doctor to see an eye doctor for a covered exam?
No. You can schedule directly with an ophthalmologist or optometrist who accepts Medicare. You do not need a referral from your primary care doctor for a covered eye exam. If you are in a Medicare Advantage plan, check your plan's rules, as some plans require referrals.