Understanding Your Vision Plan Under Medicare

Do you have trouble understanding the vision benefits associated with your Medicare plan? Many people who have enjoyed a quality vision plan as part of their employee benefits package during their working adult life are quite surprised when they turn 65 and convert to Medicare and a supplemental insurance plan. Unfortunately, the annual comprehensive vision exam and eyeglasses or contacts lenses may no longer be a part of their plan. But eye care becomes more and more important as we grow older. Not only does our vision tend to change, but the probability of developing eye conditions or diseases increases as well.

No Coverage for Routine Eye Exams

Patients are often surprised when they call to make an appointment for their annual eye exam and inform the office staff that they have enrolled in Medicare. The receptionist usually responds, "Okay, great! Thank you for giving us that information. I do want to make you aware that while Medicare does cover medically necessary eye care and office visits, it does not pay for routine eye exams."

The patient’s reaction is usually "What?!" It's true. Medicare will not cover routine vision exams, period. Medicare is designed similarly to other health insurance policies in that they pay for eye examinations when the patient’s complaint or previous diagnosis is medical in nature. "Routine" suggests a simple screening. Although Medicare is starting to approve more and more procedures and exams that are indeed health screenings, for the most part, it does not cover exams when the chief complaint is, "I need new trifocals" or "I need a vision exam."

For example, let's say that at the end of the examination, your healthcare provider diagnoses you with three different eye conditions or diseases. If you had gone into the exam room that day for a "routine" eye exam and stated that you were not having any problems with your eyes, Medicare will not pay for that exam. (Medicare will, however, cover subsequent examinations and tests to follow those previous eye conditions or diseases that were detected.)

Is Any Eye Care Covered by Medicare?

You may be wondering what eye and vision care is covered by Medicare and your supplemental policy. Well, let’s say you move to a new city and find a new eye doctor. The reason for the visit? A couple of years ago, your last eye doctor diagnosed you with mild cataracts and found a little spot on your retina. Those are medical diagnoses and medically necessary reasons for having another eye examination. However, your glasses are now a bit old and falling apart. You need to have your prescription checked and you want to invest in a new pair of no-line, progressive bifocal eyeglasses. To you, you are scheduling a simple eye exam. To your healthcare provider, however, it looks something like this:

• 92004 - Comprehensive eye examination
• 92015 - Refraction

"92004" is a code used by healthcare providers to indicate to insurance companies and Medicare that a comprehensive eye exam was performed. "92015" is a code for refraction. Refraction is the determination of your refractive error, or your prescription for glasses. Assuming the Medicare allowable fee for an exam is $135.00, Medicare will cover 80% of $135.00, which is $108.00.

Your supplemental "Medigap" insurance, such as AARP or American Pioneer, will cover the remaining 20%, or $27.00. If you have no Medigap or Medicare supplemental insurance, then you will be responsible for the $27.00. Medicare and most insurance plans consider the refraction a non-covered service. (For this exam, let's say the practitioner is charging $25 for the refraction, the part of the exam in which the doctor or technician asks "Which one is better, one or two?") So, you also must pay the refraction fee of $25. As a result, your total out-of-pocket expense for the eye examination is $25 if you have a supplement, or $52 if you don't.

Does Medicare Cover Eyeglasses?

Unfortunately, Medicare only covers basic frames and lenses directly following cataract surgery, and only once per lifetime. (Medicare will sometimes pay twice if the cataract surgery between the two eyes is separated by some extended length of time.) To help with the cost of your eyeglasses, it never hurts to ask your optician for a discount on the glasses. Some will offer a discount for AAA, senior citizens, or maybe a discount plan put forth by AARP. Also, most opticians will be happy to offer you a 10 to 20% discount if you intend to pay for the glasses in full on the day of the exam.

Medicare and Medical Eye Problems

Even though Medicare does not pay for annual, routine eye exams, medical office visits and eye exams are covered. If you are having a medical eye problem such as blepharitis or dry eye syndrome, Medicare will pay for any and all necessary medical visits to treat the problem.

A Word From Verywell

Although Medicare does not cover regular vision screenings or routine eye exams, it does pay for health screenings for glaucoma. In the year 2000, Medicare developed an office visit code for glaucoma screenings. A glaucoma screening can be performed for patients once every year for individuals with diabetes, a family history of glaucoma, who are African American over age 50, and who are Hispanics aged 65 and older. Glaucoma screenings consist of a dilated examination with intraocular pressure measurement and a slit lamp examination.