Original Medicare, which is the traditional fee-for-service U.S. government program, excludes routine vision care such as an annual eye exam and corrective lenses. However, Medicare benefits cover the fees charged by both ophthalmologists and optometrists for covered services; for example, an ocular illness or injury to the eye. The decision of which eye specialist to visit should depend on your medical need.
Difference Between an Ophthalmologist and Optometrist
An ophthalmologist is a medical doctor whose specialty is diagnosing, treating and operating on the eyes. An optometrist is licensed to perform eye exams and prescribe corrective lenses. While optometrists can treat commonplace eye ailments such as typical eye infections, they are not medical doctors and cannot perform surgery.
Eye Care Services Covered by Original Medicare
Even though routine vision check-ups, eyeglasses, and contact lenses are not covered by Medicare, there are vision-related surgeries and care that will likely be covered by Medicare. For instance, conventional intraocular lenses (IOL) implanted in the course of cataract surgery would be covered. In this case, the lenses must be inserted by an ophthalmologist while the surgery is taking place. The IOL replaces the eye’s crystalline lens, which becomes cloudy or opaque when someone has cataracts.
Glaucoma screening, if covered, is subject to a deductible and co-payments/coinsurance. The coverage is contingent upon the beneficiary being high-risk. For a Medicare recipient to be considered high risk, they may suffer from diabetes, have a family history of glaucoma, are African-American and 50 years old or more, or are Hispanic-American and 65 years old or more. This glaucoma screening can be performed by an optometrist or ophthalmologist.
When Medicare Covers Eye Exams
Other eye-related services may be covered under specific circumstances. As a result of a birth defect, traumatic incident or surgery, some people have eye prostheses. Medicare benefits in this case would include five-year replacements, polishing and resurfacing.
Another scenario would be for patients who have either diabetes or present symptoms of an ocular disease. In these special cases, eye exams would be covered. If someone has a diabetic diagnosis but shows no symptoms, it is recommended that they have routine eye exams every year. This would be covered whether the exams are conducted by an ophthalmologist or optometrist. For those with age-related macular degeneration, some diagnostic tests and associated treatments may be covered.
If you are enrolled in a Medicare Advantage plan, you will have at least the same benefits as Original Medicare Part A and Part B, but many Medicare Advantage plans will include additional coverage, including vision care. If you are having vision problems, do not hesitate to seek medical attention.