Vision Care for Older Adults: What’s Covered and What’s Not?

Vision care is essential for many seniors who need regular eye examinations or use prescription glasses or contact lenses. Reliable premium coverages can help you offset or waive the costs associated with the vision care services. Unfortunately, Medicare offers limited coverage for vision, and in some cases, no coverage at all. Lack of insurance coverage means you may need to pay out of pocket for these services. Read on to learn what type of vision care facilities are provided by Medicare programs. 

What Vision Care for Older Adult Does Medicare Plan Cover?

There are certain conditions under which Original Medicare (both Part A and B) will cover all or some of the vision care expenses for older adults. 

Let’s discuss what each part of the Medicare plan covers:

Medicare Part A Plan

Part A provides vision care only when the vision condition is declared a medical problem, such as a medical emergency or traumatic injury requiring hospitalization. Medicare Part A won’t cover routine vision examinations and eye refractions. Medicare recipients must pay the entire cost unless they have other vision coverage.

Part B Coverage

The Medicare Plan B (Medical Insurances) provide funds for physician visits, outpatient settings, and medical equipment for specific vision care treatments, such as: 

• Eye cancer.
• Detached retina.
• Eye prostheses.
• Scratched eye.
• Annual glaucoma screening for risky individuals.
• Medical diagnosis as well as therapy for macular degeneration.
• Cataract surgical treatment and prosthetics lens replacement.

It is essential to note that while Medicare Part B supports treatment for some of these conditions; it doesn’t cover all the expenses. Typically, Medicare will cover 80% of the cost of treatment, leaving you accountable for the remaining 20% ​​in addition to the Plan B deductible and premiums.

Medicare Part C

The Medicare Advantage, also called Part C, provides an alternative way to get Medicare benefits. MA (Medicare Advantage) plans are administered through private insurance firms contracted with Medicare and they often provide supplemental vision benefits not offered by Original Medicare.

Furthermore, some Medicare Advantage plans include comprehensive coverage for regular eye checkups, frames, glasses, and contact lenses. When a Medicare Advantage plan provides routine vision benefits, your premium costs might be higher than those incurred by Medicare Advantage plans that do not offer regular vision benefits.

Some Medicare Advantage plans cover routine vision exams, vision correction equipment, and other vision care.

To be sure, check the vision benefits of your specific Medicare Advantage program before enrolling in a health plan. 

Medicare Part D

Part D coverage provides prescription drug coverage, which can be added to your Medicare Part A and Part B (Original Medicare) coverage. 

The Medicare drug plans are accessible through private, Medicare-authorized insurance companies.

Certain items related to vision care, such as eye drops or other vision medicines prescribed by a physician, might be covered by a Medicare Advantage Prescription Drug plan or Medicare Prescription Drug Plan.

Medicare Vision Coverage – Medigap

Medigap insurance plans don’t offer routine vision care benefits.

Medicare Coverage for Eye Exams

Typically, Original Medicare does not cover routine eye exams for contact lenses or eyeglasses. Nevertheless, there are some exceptions because the Medicare plan can provide coverage for vision care and eye exams if a person has diabetes, macular degeneration, glaucoma, or has had cataract surgery.

Diabetes-Related Eye Examinations

Part B might include diabetes-related eye examinations if you have diabetes. This provides medically needed services and covers 80% of the cost of diabetic retinopathy vision exams once a year. In a hospital outpatient facility, you will pay 20% of the Medicare-authorized amount, including copayments and deductibles.

Eye Exams for Glaucoma

If you’re at high risk for glaucoma (an eye disease that can lead to blindness), you might be eligible for up to 80% coverage for glaucoma eye exams under Medicare Part B. State-certified eye doctors must supervise these screening tests.

Medicare Part B will cover glaucoma eye examinations every 12 months if you are at high risk for diabetes or have a family history of glaucoma.

Age-Related Macular Degeneration

Medicare Part B includes specific screening tests, such as eye disease treatment, certain injected drugs, and various other conditions for persons with age-related retinopathy or macular degeneration.

Surgery for Cataracts

Medicare Part B will include the cost of corrective eyeglasses if a person has cataract laser surgery to transplant an intraocular lens. This program provides corrective lenses with one pair of standard-frame eyeglasses or one set of prescription lenses. You would pay 20% of the Medicare-approved amount.

How Much Do Medicare Eye Exams Cost?

As previously stated, Medicare typically does not cover routine eye exams, but there are some exceptions for high-risk patients.

Without health coverage, the average cost of an eye exam is between $50 and $70. Most insurance plans do not cover routine eye exams, and there could be additional copays. You would be responsible for the entire cost because Medicare does not cover regular eye exams. 

Eye Exams for People who have Glaucoma or Diabetes

If you have diabetes or glaucoma, Medicare Part B may cover annual eye examinations once a year. 

For example: 

You will be covered for 80% of the exam if you use the Part B coverage for the glaucoma eye exam. After you’ve met your Part B deductible, you’ll still be responsible for the remaining 20% of the Medicare-authorized amount.

Eye Exams for Macular Degeneration

Medicare Part B may cover specific screening tests. It includes the treatment of certain eye disorders and diseases, such as age-related retinopathy, which causes vision loss. You would be liable for paying 20% of the costs for these vision care services, in addition to the copayments and deductibles.

Cataract Surgery for Eye Exams

Medicare Part B may cover the cost of corrective lenses if you need cataract surgery to transplant an intraocular lens. You’d also get one pair of standard frames eyeglasses or one set of prescription lenses if it’s medically necessary after cataract surgery.

What Vision Care for Older adult does Medicare won’t Cover?

The Medicare plan does not support traditional vision care services unless considered a medical emergency, as in previous cases. Therefore, you will be responsible for almost 100% of the cost of any eye care you receive if you don’t have separate vision insurance. 

Medicare does not subsidize the following vision care assistance:

• Prescription sunglasses or eyeglasses.
• Regular eye tests.
• LASIK surgical treatment.
• Contacts.

Options for Vision Health Insurance

Vision medical care coverage can be significant for people who require regular eye tests or wear contacts or prescription eyeglasses. 

The coverage gap for senior citizens who no longer receive vision insurance from their employers can be shocking. Fortunately, there are several alternatives you can choose to supplement your vision coverage as a member of Medicare. 

Stand-Alone Vision Insurance Coverage

Vision care services for seniors are also available as part of supplemental vision plans. Stand-alone vision insurance plans typically have low monthly premiums but may have coverage limits depending on the program. Since PPO and HMO insured these stand-alone plans, you are also confined to their service networks. Many programs may help pay for eye treatments and offset the cost of contact lenses and prescription glasses.