Medicare and Medicaid
Different kinds of vision care are included in Medicare and Medicaid programs that the U.S. government funds for qualifying Americans age 65 and older, individuals with specific disabilities and people with low income.
To access vision services, you first need to understand what kind of Medicare and/or Medicaid plan you have and exactly what types of vision care are associated with each particular plan.
Medicare: What Kinds of Vision Care Are Available?
Medicare has three parts that address different needs:
- Medicare Part A (Hospital Insurance). Medicare Part A helps pay the costs incurred while in a hospital or rehabilitation facility. It also covers costs associated with home health care and hospice care. Medical problems of the eye that require hospital emergency room attention are covered, but routine eye exams are not covered.
- Medicare Part B (Medical Insurance). Medicare Part B covers part of the costs of doctor visits and some other medical services not included in Part A, such as lab tests and medical equipment. Visits to an eye doctor that are related to eye diseases often are covered, but not routine eye exams.
- Medicare Part D (Prescription Drug Coverage). Medicare Part D helps pay the costs of prescription drugs, including medicines for eye diseases such as glaucoma.
Another way to obtain Medicare benefits is to enroll in a Medicare Advantage Plan. These plans (also called Medicare Part C) are health plans run by Medicare-approved private insurance companies that combine the benefits of Medicare Parts A and B, usually along with additional benefits such as Medicare Prescription Drug Coverage (Part D).
More About Vision Benefits Offered Under Medicare, Parts A and B
Participants in Medicare Parts A and B ("original Medicare") generally are eligible for the following types of vision coverage. Amounts and conditions may vary by state, and you must pay an annual Plan B deductible ($162 in 2011) before Medicare begins to pay its share.
Also, Medicare beneficiaries have a coinsurance obligation. This is the amount you are required to pay as your share of the costs for services after you pay any deductibles.
In most cases, you are required to pay 20 percent of Medicare-approved amounts for medical services provided.
- Cataract surgery. Medicare covers many of the costs associated with cataract surgery, including the cost of a standard intraocular lens (IOL) used to replace your eye's natural crystalline lens that has become clouded by a cataract.
If you choose a premium intraocular lens, such as a multifocal IOL to correct your eyesight at all distances and thereby reduce your need for reading glasses after surgery, you must pay the added cost for this IOL (above the cost of a standard IOL) out-of-pocket.
- Eyewear after cataract surgery. Medicare helps pay for one pair of eyeglasses or contact lenses after cataract surgery. Only standard eyeglass frames are covered.
- Glaucoma screening. Medicare helps pay the cost of an annual glaucoma screening for individuals at high risk for glaucoma, including people with diabetes or a family history of glaucoma and African-Americans who are age 50 or older. Glaucoma screening consists of a comprehensive eye exam, including dilation and intraocular pressure (IOP) measurement.
- Ocular prostheses. Medicare helps pay the costs associated with replacement and maintenance of an artificial eye.
Medicare Supplement (Medigap) Insurance Policies
To expand coverage beyond what is provided by Medicare Parts A and B, eligible candidates can purchase a Medicare Supplement Insurance policy (also called a Medigap policy).
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A Medigap policy is health insurance sold by private insurance companies to supplement ("fill gaps") in the coverage provided by original Medicare (Parts A and B).
Medigap policies often cover your share of the costs of Medicare-covered services, including coinsurance, co-payments and deductibles.
Some Medicare Supplement policies also cover certain benefits that original Medicare doesn't cover, including routine eye exams, eyeglasses and contact lenses.
Medigap policies are intended to supplement Medicare Parts A and B coverage only. Insurance companies generally cannot sell you a Medigap policy if you have a Medicare Advantage Plan (Part C) or are covered by Medicaid.
For more details about Medicare plans and coverage including Medicare Advantage and Medigap insurance policies visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227).
Page 3 of 3: Medicaid and Vision Benefits
[Page updated February 5, 2014]
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