Medicare coverage for vision services is extremely limited, although coverage is more robust if you have diabetes.
Among the different forms of care that Medicare provides, vision can be one of the hardest to understand. Although Medicare does provide vision care under some circumstances, most routine vision care isn’t covered at all. This gets even more varied when you add Medicare Advantage into the mix.
Vision care for diabetes is unique among the forms of vision care available. We’ll go through what your options are for diabetes care under both Medicare Advantage and Original Medicare, as well as additional things that can be useful when navigating these scenarios.
Understanding Medicare Vision Coverage
Even if you require specialized diabetes-related vision care, understanding the more common forms of routine vision care is still important. Let’s take a look at what you can expect if you need vision care and are covered by Medicare.
Unfortunately, Medicare does not provide coverage for vision care, with few exceptions. Routine vision care refers to care that you may get in support of your overall visual system, such as routine eye exams. If you have glasses or contacts, this can include things like eye prescription tests, eyeglasses, and contact lenses.
If you need a pair of glasses or know that you have vision problems, make sure that you get some form of vision care coverage when you transition to Medicare. Many Medicare Advantage plans offer vision coverage, which we will discuss in more detail below. However, if you have Original Medicare, you will need another private vision plan; there’s no way around it.
Glaucoma Screenings for High-Risk Beneficiaries
Medicare does provide an annual glaucoma screening for individuals who are at a higher risk of visual impairment and eye disease. This doesn’t cover routine visual care or glasses but will cover other forms of vision care that many people need to rely on.
In order to qualify for the annual glaucoma screening, you must satisfy one of the following conditions:
- You have diabetes
- You have a family history of glaucoma
- You are African American and over 50 years old
- You’re Hispanic and over 65 years old
In order to get your glaucoma screening covered, make sure that it’s administered by a doctor that is authorized to provide this care in your state. Under Part B, you will pay 20 percent of the Medicare-approved amount of the screening once you've reached your Part B deductible. The screening may also be available in a hospital outpatient setting, in which case you will also pay an additional copayment.
Screenings for Diabetic Retinopathy
Diabetic retinopathy is an ocular condition that specifically afflicts diabetic patients as a result of issues relating to blood sugar levels in the back of the eye. While this condition doesn’t affect everybody, it is important to make sure that you get screened if you do have diabetes.
Diabetic retinopathy screenings are covered under Part B of Medicare under some circumstances. Part B covers your screenings if you have diabetes, and your exam is performed by an eye doctor who is legally allowed to do so in your state.
Cataract Surgery Coverage
Although cataract surgery is a form of eye care, it will be covered by Part B health insurance in many cases. You'll get this same coverage if you have a Part C plan, even if it doesn't include vision benefits.
If you need corrective lenses as a result of intraocular lens surgery, these will be covered by Part B even though they normally are not.
Age-Related Macular Degeneration Screenings
Although not directly linked to diabetes, medical care related to macular degeneration is also notably covered by Medicare. You’ll be able to get coverage for both macular degeneration tests and some outpatient procedures as well as prescription drug coverage. The overall situation is similar to the other covered services described above: you will pay the 20 percent Medicare Part B coinsurance once you’ve met your deductible.
Coverage Under Medicare Advantage
Medicare Advantage, also known as Medicare Part C, is a way to receive your Medicare benefits through a private insurance company. Medicare Advantage plans are required by law to provide you with the same coverage as Original Medicare (Medicare Part A and Medicare Part B). However, there are some other notable differences.
Part C plans will vary in cost, while Original Medicare will cost the same no matter where you are. These plans can also have other restrictions, like provider networks. One of the biggest differences is that Part C plans can offer additional benefits, even though they can’t offer less.
For this reason, some Medicare Advantage plans may offer additional vision coverage. While this isn’t universal, it is not uncommon to find Medicare Advantage plans that cover routine vision care as well as other forms of vision care that may be relevant to your situation.
Note that the care options for diabetic retinopathy screenings that are described above will always be covered by Medicare Advantage, so you never have to worry about this carrying over if you qualify under Original Medicare.
Coverage from Part D Prescription Drug Plans
If any of your vision care requires prescription drugs, such as eye drops or another form of medication, then you will need an additional plan for coverage. With very few exceptions, Original Medicare doesn’t cover prescription drug costs. However, note that some Medicare Advantage plans do have prescription drug plans built-in.
Part D prescription drug plans are also offered by private insurance companies, so the costs and details will vary. Make sure that you look at a given plan’s formulary to figure out whether or not it contains the drugs that you need access to.
Many Medicare beneficiaries with diabetes will find Part D plans very useful to have in any case, since they can provide coverage for additional prescription drugs that are needed by diabetic patients.
Can Medigap Plans Help?
Medigap plans, also known as Medicare Supplement plans, are private insurance plans that help cover your out-of-pocket costs under Original Medicare. While these plans can’t directly provide coverage for your vision care, they can help cover out-of-pocket costs that you incur as part of your diabetes care.
For example, some plans will cover your Part B coinsurance. This means that when you get your vision screenings, your plan will pay the coinsurance for you, once you’ve paid your monthly premium.
Understanding whether or not these plans are worthwhile for you involves many other considerations, but they are good for any Medicare beneficiary to keep in mind.
Key Things to Remember About Diabetic Vision Coverage Under Medicare
Although Medicare doesn’t provide routine vision coverage, it does provide some screening options for diabetic patients and other at-risk beneficiaries. Aside from this, you should have a plan for your vision coverage if you know you need it. Take a look at Medicare Advantage plans that offer this type of coverage, as well as other independent private vision plans.
Eye exam coverage for diabetes
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Medicare Coverage for Routine Vision Services
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