Does Medicare Cover an Ophthalmologist? 

As children and young adults, our eyesight is tested regularly. As we get older, many of us neglect to care for our vision unless we experience a change or loss of function. We’ll make an appointment to visit an eye doctor when we find ourselves squinting to see street signs or reading a book. Many of us put off check-ups when we’re feeling healthy, but seeing an ophthalmologist regularly can be important.  If you have Medicare, you’ll want to know if a visit to an ophthalmologist will be covered by your benefits.

Regular vision exams with an ophthalmologist are important throughout life, but they become even more significant for adults over 65. Not only can ophthalmologists diagnose and treat several eye diseases, but they can also evaluate risk factors for other medical conditions, so you can get screened and treated for them as well.

Many eye diseases that are common in seniors don’t show any symptoms until vision has already been affected. By visiting your ophthalmologist for routine check-ups, you can protect your eyesight from conditions like age-related macular degeneration, glaucoma, and ocular melanoma. And of course, you should see an ophthalmologist immediately if you have an eye injury, have sudden changes in your vision, or if you have an eye infection.  

If you’ve already been diagnosed with diabetic retinopathy, glaucoma, cataracts, or macular degeneration, you’ll need to have regular visits, so your ophthalmologist can monitor your progress, make changes in treatments, or recommend surgery if necessary. 

Does Medicare cover visits to an ophthalmologist? 

Original Medicare Part B (medical insurance) doesn’t cover routine vision care like annual eye exams, eyeglasses, or contact lenses. However, Medicare does cover visits to ophthalmologists and optometrists for certain medically necessary services, such as those listed below:

• A glaucoma screening once every 12 months if your physician certifies that you’re at high risk of developing glaucoma because you have diabetes, a family history of glaucoma, you’re African American and 50 or older, or you’re Hispanic and 65 or older. 
• An annual eye exam for diabetic retinopathy if you have diabetes 
• Eye exams that are medically necessary due to trauma, surgery, ocular disease symptoms, birth defects, etc. 
• Diagnostic tests and treatment (eye drops and injections) for age-related macular degeneration 
• Cataract diagnostic exams and surgery (in an outpatient setting)
• Intraocular lenses that are implanted during cataract surgery

If you’re eligible for coverage, Original Medicare Part B pays 80 percent of the final approved cost if you get care from an ophthalmologist, optometrist, or other health care provider who accepts Medicare assignment. You pay the remaining 20 percent after you’ve paid your Part B deductible for the current year.  Most people have to pay a monthly premium for Part B coverage.

Original Medicare Part A (hospital insurance) covers your cataract surgery if your ophthalmologist admits you for inpatient care in a hospital that accepts Medicare assignment. In this instance, you must cover your deductible for the benefit period before Medicare Part A pays its share of the cost of your surgery and hospital stay. 

If you’re enrolled in a Medicare Advantage (MA) plan, you are entitled to receive the same benefits as those provided by Original Medicare Parts A and B.  Today, most Medicare Advantage plans also include additional coverage and extra benefits that can include routine vision care. This means that you may be able to visit an ophthalmologist for routine eye checks more often.

Depending on the type of plan you have, you may need to visit in-network ophthalmologists and optometrists to get coverage, so check your plan policy or contact your provider for details about your benefits before making health care appointments.  MA benefits and costs vary from plan to plan, so review your benefits or contact your plan directly if you have questions.