Eye Health is Important!
As you age, your risk for vision impairment and vision loss grows.
Because some vision-threatening conditions are not readily noticeable, it is
important that you preserve your vision by maintaining a healthy lifestyle
and having an eye exam through dilated pupil every 1-2 years or as
recommended by your eye doctor. Half of all blindness can be prevented
through early detection and treatment.
Medicare beneficiaries, especially those at risk for or diagnosed with a
variety of diseases, are entitled to a number of vision-related services.
It is especially important for people with diabetes, a family history of
glaucoma, or those who have suffered an eye disease or injury to be aware
of and utilize these benefits. Below are details about medical benefits that
may be available to you. See the “Need More Help” section for whom to
contact for additional assistance.
“Welcome to Medicare” Preventive Visit
The “Welcome to Medicare” visit is an excellent way for you to get upto-
date on important screenings and vaccinations, as well as to talk with
your health care provider about how to stay healthy. You can get this
introductory visit only within the first 12 months you have Medicare
Part B (medical). This visit is covered one time. Your doctor will:
Record and evaluate your medical and family history, current health
conditions, and prescriptions.
Check your blood pressure, vision, weight, and height to get a baseline for
your care. Keep in mind the vision check is a screening for vision loss risk
factors, not an eye exam through dilated pupil.
Make sure you’re up-to-date with preventive screenings and services, such
as cancer screenings and shots.
Order further tests, depending on your general health and medical history.
Following the visit, your doctor will give you a plan or checklist with
screenings and preventive services that you need. Ask about eye exams!
and Your Eyes
Routine Eye Exams
Medicare does not generally cover the costs of routine eye exams,
with some exceptions. Medicare does help cover the exam if you have
diabetes, or are at risk for glaucoma. Keep in mind that Medicare does
not cover refractions for eyeglasses or contacts even as a part of some
otherwise covered exams. Check with your eye care professional for
more information. Medicare does not cover eyeglasses or contact lenses,
except immediately following cataract surgery. Medicare does cover an
eye exam for medical reasons, such as in the case of injury or disease.
Medicare Advantage plans, which are administered by private companies,
may choose to offer vision coverage and beneficiaries also have the
option to purchase supplemental coverage (Medigap) in addition to their
Medicare coverage that may cover routine eye care or help to cover the
cost of deductibles and other fees.
Glaucoma is called “the sneak thief of sight” because often there are
no warning signs, but there is treatment for glaucoma if detected early.
A leading cause of blindness, glaucoma affects close to 2.7 million
Americans age 40 and older.
Medicare provides annual coverage for glaucoma screenings if you are
considered to be at high risk for glaucoma. High risk is defined as:
»» Individuals with a family history of glaucoma – family defined as a
blood parent or sibling;
»» Individuals with diabetes – either diet-controlled, oral-agent
controlled, or insulin-dependent;
»» African Americans age 50; and
»» Hispanic individuals age 65 or older.
The exam for glaucoma includes:
»» Visual acuity;
»» Dilated eye examination;
»» Intraocular pressure measurement; and
»» Direct ophthalmoscopy.
Medicare will cover 80 percent of the doctor’s exam fee. You or your
secondary insurance must pick up the deductible and the remaining 20
percent balance. A minimum of 366 days is required between glaucoma
and Your Eyes
If you have diabetes, you are at risk for developing diabetic retinopathy,
glaucoma, and cataracts. Diabetic eye disease can affect anyone with
diabetes. Often there are no symptoms, so it is important to see your eye
care professional for a comprehensive eye exam.
Medicare beneficiaries with diabetes qualify for the annual glaucoma
screening benefit. This benefit includes a comprehensive eye exam.
Because people with diabetes need to have an eye exam at least once
a year, Medicare beneficiaries should be sure to make full use of the
yearly glaucoma screening benefit to receive an eye exam that can check
for both glaucoma and diabetic retinopathy. See “Medicare Benefits for
Glaucoma” on previous page for details.
Cataract affects millions of Americans and are a leading cause of
blindness worldwide. In the U.S., cataract surgery is the most commonly
performed surgical procedure in those 65 and older.
Medicare beneficiaries have two choices for cataract surgery: receiving
basic lens replacement (IOL), paid in full by Medicare up to $2,000, or
applying the credit to new replacement lenses that can correct both near
and farsightedness (multifocal IOLs), in addition to cataract removal.
Patients are then responsible for paying the difference.
Medicare also covers corrective eyeglasses or contacts following
cataract surgery with an implanted intraocular lens. Medicare pays 80
percent of the Medicare-approved amount for one pair of eyeglasses or
contact lenses after each cataract surgery. The beneficiary also pays any
additional charges for upgraded frames and the Part B deductible.
Age-related Macular Degeneration (AMD)
AMD diminishes central vision that currently affects the vision of more
than 2 million Americans age 50 and older and is a leading cause of
blindness. AMD is a progressive disease that, if left untreated, can result
in severe vision loss and even blindness.
Medicare Part B covers treatment for beneficiaries with age-related
macular degeneration, including lucentis, Avastin, aflibercept, pegaptanib,
and ocular photodynamic therapy with verteporfin (Visudyne). The
beneficiary pays 20 percent 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.
and Your Eyes
Prescription Drug Benefits
All Medicare beneficiaries, no matter how they get their health
care today or whether they have existing drug coverage, are
eligible for drug coverage under a Medicare prescription drug
plan (also known as a Part D plan). This includes eye medications.
There are penalties for people who miss enrollment deadlines
»» October 15 – annual open enrollment period begins
»» December 7 – annual open enrollment period ends
»» January 10 – new choices take effect
Medicare prescription drug plans will vary depending on where
you live, and each plan is different. This can be confusing, but
there are resources which can help you to understand your
choices. Start with www.Medicare.gov and 1.800.MEDICARE.
Financial assistance is available for those who meet certain
income and resource limits. Contact Social Security at
1.800.772.1213 or visit www.socialsecurity.gov to learn more
about this program.
Need More Help?
Centers for Medicare and Medicaid Services:
1.800.633.4227 or www.medicare.gov
1.800.772.1213 or www.socialsecurity.gov
State Health Insurance Assistance Program (SHIP)
Each state has a SHIP program funded by Medicare which
provides objective information about Medicare related issues.
One-on-one counseling and assistance is available to people
with Medicare and their families. To find the SHIP program in
your state go to: www.shiptalk.org
Prevent Blindness America Vision Health Resource Center
1.800.331.2020 or www.preventblindness.org