Much like dental care, vision care has long taken a back seat to other health factors in the insurance arena. The gradual recognition of its importance to overall health, however, means more options for consumers. 

Coverage for vision care* may come from:

• Group plans through an employer 
• Privately-purchased medical or vision insurance 
• Medicare 
• Medicaid 
• State children’s health insurance programs (CHIP)
• Other public or private programs 

No two programs are exactly alike, so read your insurance plan closely to ensure that you understand what it does, and doesn’t, cover.

Insurance and eye health 

Both vision and medical insurance can be used in your optometrist or ophthalmologist’s office, but the reason for your visit determines which insurance plan pays for it. 

Vision insurance will cover the visit if it relates to a refractive error, such as:

• Astigmatism
• Nearsightedness
• Farsightedness

Medical insurance will cover visits associated with medical conditions like:

• Glaucoma 
• Cataracts
• Conjunctivitis

If you don’t have health insurance, you may be eligible for subsidies to help you afford a plan through your state’s health insurance marketplace. Your child may also be eligible for either Medicaid or your state’s CHIP. 

Children’s vision services 

As of January 1, 2014, coverage for children’s vision was mandated as part of an “essential health benefits” bundle provided by all:

• Individual health insurance plans 
• Small group insurance plans
• Plans sold in the new state-based health insurance marketplaces

In many states, this means coverage for one comprehensive eye exam and one pair of glasses each year, including vision screening for children without a copay or coinsurance. 

“Welcome to Medicare” 

The “Welcome to Medicare” visit is a one-time introductory visit limited to the first 12 months that you have Medicare Part B. 

During this visit, your doctor will:

• Record your medical history, family history, health conditions, and prescriptions.
• Assess your blood pressure, vision, weight, and height.
• Check for vision loss risk factors.
• Bring your preventative screenings and services up-to-date.
• Order further tests as necessary.

Routine eye exams 

Medicare does not usually cover routine eye exams unless there is a medical reason such as injury or disease, including diabetes and glaucoma. Medicare also does not cover:

• Eyeglasses or contact lenses (unless immediately following cataract surgery)
• Refractions for eyeglasses or contacts

Glaucoma 

Medicare provides annual coverage for glaucoma screenings for those considered to be at high risk, defined as:

• Close family member (parent or sibling) with glaucoma 
• Individuals with diabetes, either diet-controlled, oral-agent controlled, or insulin-dependent 
• African Americans age 50 or older
• Hispanic people age 65 or older 

Examination coverage for glaucoma includes:

• Visual acuity screening 
• Eye exam with dilation
• Intraocular pressure (IOP) measurement
• Direct ophthalmoscopy (examination of the back of your eye using a small device with a light and lenses on it)

Medicare covers 80% of the doctor’s exam fee. You or your secondary insurance are responsible for the remaining 20%, as well as the deductible. There is a required wait time of at least 366 days between glaucoma screenings. 

Cataract surgery 

Cataract surgery is the most commonly performed surgical procedure in adults 65 and older in the U.S. Medicare beneficiaries have two choices for cataract surgery in addition to the cataract removal: 

• You can receive basic lens replacement, paid in full by Medicare (up to $2,000). 
• You can apply the credit to new replacement lenses that can correct both near- and far-sightedness.

You are responsible for paying the difference. Medicare also covers corrective eyeglasses or contacts following cataract surgery with an implanted intraocular lens (IOL). 

Age-related macular degeneration

Age-related macular degeneration (AMD) is a progressive disease that can diminish central vision and lead to blindness. Medicare Part B covers treatment for beneficiaries with AMD. 

Covered treatments include:

• Avastin 
• Eylea 
• Lucentis 
• Pegaptanib
• Ocular photodynamic therapy with verteporfin (Visudyne) 

The beneficiary pays 20% of the Medicare-approved amount for the drug and the doctor’s services or a co-payment if the treatment is offered in a hospital outpatient setting. 

Prescription drug benefits 

All Medicare beneficiaries, regardless of whether or not they have existing drug coverage, are eligible for drug coverage, including eye medications, under a Medicare prescription drug plan (Part D). 

Medicare Advantage 

Medicare Advantage plans are administered by private insurance companies and are available to all Medicare-eligible individuals. They must cover all the services covered by traditional Medicare. Most plans cover routine eye exams and offer a glasses or contact lens benefit.

*Prevent Blindness. (n.d.). Health Insurance and Your Eyes. https://preventblindness.org/health-insurance-and-your-eyes/