WHAT VISION CARE IS COVERED UNDER MEDICARE?
Vision care under Medicare is very limited, and often misunderstood! Under most circumstances Medicare does not pay for your eye care.
Medicare does cover medically necessary eye care and office visits, it does not pay for routine eye exams.”
Medicare will not cover routine vision exams, period. Medicare is designed similar 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 develop 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 doctor 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 doctor, however, it looks something like this:
- 92004 – Comprehensive eye examination
- 92015 – Refraction
“92004” is a code used by doctors 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 Physicans Mutual 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 doctor 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. Also, most opticians will be happy to offer you a 10-20% 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.
Medicare and Glaucoma Screenings
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 interocular pressure measurement and a slit lamp examination.
One of the best and most cost effective vision plans I have found is VSP vision care for life. The site where you can find more information on this plan and sign up for it if you are interested is…Dental for Everyone There are several dental plans here also but the best I have found is Physicans Mutual and you can find more information about that at my web page… larrydgaddisfsg.com
Centers for Medicare and Medicaid Services. Medicare Coverages. Department of Health and Human Services, 2009.