Medicare covers one eye exam every 12 months if you have diabetes or age-related macular degeneration, and one exam every 24 months for all other beneficiaries
Medicare Part B covers a dilated eye exam once every 12 months if you have been diagnosed with diabetes or age-related macular degeneration (AMD). If you do not have either condition, Medicare covers one exam every 24 months. The exam must be performed by an ophthalmologist or optometrist who accepts Medicare, and you pay 20 percent of the approved amount after you meet your Part B deductible.
The key distinction is that Medicare covers the medical eye exam — the one that screens for disease — not the routine vision exam used to write a glasses or contact lens prescription. If you need an exam primarily to update your prescription, Medicare does not cover that visit. Many people need both types of exams in the same year, which means paying out of pocket for the vision exam portion.
Key Takeaways
- Medicare covers one dilated eye exam every 12 months if you have diabetes or age-related macular degeneration, and every 24 months if you do not have either condition.
- You pay 20 percent of the Medicare-approved amount after meeting your Part B deductible; the exact dollar amount varies by provider and location.
- Medicare does not cover routine vision exams for glasses or contact lens prescriptions, only medical exams that screen for eye disease.
- Your eye doctor must be enrolled in Medicare and accept Medicare assignment for the 20 percent coinsurance to explore; out-of-network providers may charge more.
- If you have a Medigap or Medicare Advantage plan, your coverage for the coinsurance amount may differ from Original Medicare.
Who qualifies for the more frequent exam schedule
You are may be able to access for an eye exam every 12 months instead of every 24 months if you have a diagnosis of diabetes or age-related macular degeneration documented in your medical record. Your primary care doctor or eye doctor must have recorded this diagnosis in your chart for Medicare to recognize it. If you have been diagnosed but are unsure whether it is in your Medicare file, ask your eye doctor's office to verify before scheduling.
Diabetes includes Type 1, Type 2, and gestational diabetes. You do not need to be on insulin or any particular medication — the diagnosis alone qualifies you. If you were recently diagnosed and your eye doctor is not yet aware, bring documentation of the diagnosis to your appointment so they can note it in your Medicare claim.
What Medicare actually pays and what you owe
Medicare Part B pays 80 percent of the approved amount for a covered dilated eye exam after you meet your annual deductible. You pay the remaining 20 percent, called coinsurance. The approved amount varies by location and provider, but typically ranges from $60 to $120 for the exam itself. This means your out-of-pocket cost is usually between $12 and $24 after the deductible.
Your Part B deductible for 2024 is $240 (this amount changes each year). Once you have paid $240 toward Part B services in a calendar year, coinsurance applies to all remaining covered services for that year. If you have already met your deductible through other doctor visits or tests, you pay only the 20 percent coinsurance for the eye exam.
If your eye doctor does not accept Medicare assignment — meaning they do not agree to accept the Medicare-approved amount as full payment — they can charge up to 15 percent more than the approved amount. You would then owe 20 percent of that higher amount plus the 15 percent excess charge. Always confirm that your provider accepts Medicare assignment before the visit.
The difference between a medical exam and a vision exam
A medical eye exam screens for eye disease: glaucoma, cataracts, diabetic retinopathy, macular degeneration, and other conditions. It includes dilating your pupils and examining the back of your eye. Medicare covers this exam on the schedule described above. A vision exam or refraction measures how well you see and determines your glasses or contact lens prescription. Medicare does not cover this.
Many people need both exams in the same year. For example, you might have a covered medical exam in January to check for glaucoma, then need a vision exam in October because your prescription changed. You would pay nothing (except coinsurance) for the medical exam and the full cost for the vision exam. Some eye doctors bundle these into one visit and bill Medicare for the medical portion only; others charge separately. Ask your doctor's office in advance how they will bill so you know what to expect.
How to schedule and what to bring
Call your eye doctor's office and tell them you have Medicare and want to schedule a covered dilated eye exam. Ask them to confirm they accept Medicare assignment. Bring your Medicare card and any photo ID. If you have a secondary insurance (Medigap or Medicare Advantage), bring that card too.
If you do not have a regular eye doctor, you can search for Medicare-enrolled providers on the Medicare.gov provider search tool or call 1-800-MEDICARE to get a list of ophthalmologists and optometrists in your area who accept Medicare. Some community health centers and vision clinics also accept Medicare and may have lower out-of-pocket costs if you have limited income.
Medicare Advantage and Medigap coverage for eye exams
If you have a Medicare Advantage plan (Part C), your coverage for eye exams may differ from Original Medicare. Some Medicare Advantage plans cover routine vision exams or offer vision benefits like discounts on glasses and contacts. Check your plan's summary of benefits or call the plan directly to learn what is covered. You may have a different copay or coinsurance amount than the 20 percent under Original Medicare.
If you have a Medigap policy, it typically covers the 20 percent coinsurance you would owe under Original Medicare, but does not add coverage for routine vision exams. Your Medigap plan pays its share after Medicare pays its 80 percent, so you may owe nothing out of pocket for a covered medical exam. Review your Medigap policy documents or call your insurer to confirm.
What happens if you need an exam sooner than the schedule allows
If you develop symptoms of eye disease — sudden vision changes, flashing lights, new floaters, eye pain, or halos around lights — you can see an eye doctor before your scheduled exam. Medicare will cover a medical exam for these symptoms even if you had a covered exam recently. The exam must be for diagnosis or treatment of a specific eye condition, not just a routine check-up.
Tell your eye doctor about your symptoms when you call. They will document the reason for the visit in your chart, and Medicare will review the claim to confirm the visit was medically necessary. If the visit is deemed routine rather than symptom-based, you may receive a bill for the portion Medicare does not cover.
Frequently Asked Questions
Does Medicare cover glasses or contact lenses?
No. Medicare does not cover glasses, contact lenses, or the vision exam needed to write a prescription for them. Some Medicare Advantage plans offer vision discounts, and you can purchase glasses through any retailer. If you need financial help, some nonprofits offer free or low-cost eyeglasses to seniors with limited income.
What if I have not had an eye exam in years?
You can schedule one now. Medicare will cover it on the standard schedule: every 24 months if you do not have diabetes or AMD, or every 12 months if you do. There is no waiting period or penalty for having skipped exams in the past.
Can I get an eye exam at a retail vision center like Walmart or LensCrafters?
Only if the optometrist at that location is enrolled in Medicare and accepts Medicare assignment. Call ahead to confirm. Many retail centers do accept Medicare, but some do not. If they do not accept Medicare, you pay the full cost out of pocket.
Do I need a referral from my primary care doctor to see an eye doctor?
No. Under Medicare Part B, you do not need a referral to see an ophthalmologist or optometrist. You can call and schedule directly. If you have a Medicare Advantage plan, check your plan documents — some require a referral.
What if my eye doctor says I need an exam more often than Medicare covers?
Your doctor may recommend more frequent exams based on your eye health, especially if you have glaucoma or diabetes. Any exam beyond what Medicare covers is your responsibility to pay for. Ask your doctor's office for the cost before the visit so you can decide whether to proceed.