Original Medicare doesn’t typically pay for routine yearly eye exams for corrective vision. However, Medicare Advantage plans and some Medigap plans might cover these exams.
If you are enrolled in a Medicare Advantage plan that covers these services, you’ll only have to pay 20 percent of the Medicare-assigned cost after satisfying the Part B deductible.
What is covered?
Medicare Part B, which covers costs associated with doctors’ care outside of a hospital, does cover routine eye exams for diabetics and certain cataract surgery procedures. It also covers glaucoma and other chronic eye conditions.
But Medicare does not cover LASIK or other cosmetic eye surgeries to reduce the need for glasses, and it doesn’t provide regular vision screenings. Beneficiaries can use funds from a health savings account or purchase supplemental insurance policies to help defray the cost of these services, but these aren’t always feasible options for many patients.
If a patient requests a service that you suspect may not be medically reasonable and necessary, consider requesting the patient sign an advance beneficiary notice (ABN) before providing the services. The payer’s website can often provide information on what is and isn’t covered under their policy, as well as downloadable ABN forms. Also, ask the patient if they have other insurance that might cover the service.
What is not covered?
Medicare has a number of services that are not covered, including cosmetic surgery (except where medically necessary), massage therapy and certain in-home medical equipment. You can find detailed information about what is covered and not by contacting the payer’s customer service number, which is usually on the back of your card. The payer may also have additional information about coverage guidelines on its website.
In addition, original Medicare does not cover long-term care in a nursing home or similar facility, or routine dental and vision care including glasses. However, some Medicare Advantage plans do provide these services, or you can purchase supplemental insurance policies that cover them. You can also set aside money in a health savings account and use it tax-free at any age for out-of-pocket health care expenses. Some of these accounts also allow you to buy prescription sunglasses and lenses. If a patient wants a service that is not medically reasonable and necessary, you must obtain their signature on an Advance Beneficiary Notice (ABN). ABN forms can be found on the CMS website or your payer’s website.
What is a routine eye exam?
A routine eye exam is an office visit to check vision, screen for eye disease and update prescriptions for eyeglasses or contact lenses. This is typically billed to a separate vision insurance plan.
In some cases, Medicare can pay for a regular eye exam if it is deemed medically necessary by a doctor. This is usually the case for those who have diabetes and are at high risk of developing eye conditions like glaucoma or macular degeneration.
The best way to make sure your eye exams are covered is by having a Medicare Advantage (Part C) plan that includes coverage for eye care as part of the overall package. These plans are offered through private insurance companies and function as an alternative to Original Medicare Parts A and B. Medicare Advantage plans also can offer extra benefits that are not available through Original Medicare. However, it is important to note that these extra benefits are subject to deductibles and copayments/coinsurance.
What is a specialized eye exam?
A specialized eye exam may include an external examination of the eyelids and surrounding tissues, pupil function testing, tests of extraocular muscle motility, visual fields, intraocular pressure, a direct ophthalmoscopy through a dilated pupil and other specialized tests. During these exams, health care professionals may use tools that touch your eyes, but they are generally painless and quick.
Eye specialists, such as optometrists, conduct comprehensive eye and vision exams and can provide you with a prescription for eyeglasses or contacts. They also diagnose and treat certain eye diseases and can prescribe medicine for you.
Medicare Part B covers one specialized eye exam within the first year of your coverage. Some Medicare Advantage (Part C) plans offer additional vision coverage that varies by plan. For example, some MA plans cover yearly eye exams for diabetic retinopathy. However, this coverage is subject to referrals and prior authorization. Also, MA plans typically require that you use in-network health care providers.