Eye exams, glasses and cataract surgery: what Medicare covers

Medicare's split on eyes follows the same logic as the rest of the program, once you see it: it pays to treat disease and it does not pay to correct ordinary aging. Your eyes getting worse at 70 in the way everyone's eyes get worse is not, in Medicare's framing, a medical event. Your retina bleeding because of diabetes very much is.

That line is clean in the statute and messy in a waiting room, because both things get looked at by the same doctor with the same equipment in the same appointment. What determines coverage is why the visit happened and what was found.

• Routine eye exams to check your prescription — often called refraction. Medicare specifically excludes refraction, and it will appear as a separately billed, patient-owed line even inside an otherwise covered appointment.
• Eyeglasses, frames and lenses.
• Contact lenses.
• Reading glasses.
• Elective vision correction surgery such as LASIK.

Medical eye care is covered well, and several of these are preventive services worth actively claiming:

Cataract surgery is one of the most common procedures in Medicare and one of the best covered. Part B pays for the operation, the facility fee and a conventional intraocular lens, subject to the deductible and the usual 20% coinsurance.

Then comes the exception that surprises people: after cataract surgery with an implanted lens, Medicare covers one pair of eyeglasses with standard frames, or one set of contact lenses, supplied by a Medicare-enrolled supplier. It is the only circumstance in which Original Medicare buys eyewear, and it exists because the glasses are treated as part of the prosthetic replacement of the eye's natural lens.

• It is one pair per surgery, not one per year — so a patient having both eyes done in separate operations is entitled to a pair after each.
• Standard frames are covered. If your parent upgrades the frames, they pay the difference.
• Upgrades to the lenses — progressive, anti-glare, tinting — are generally the patient's cost.
• The supplier must be enrolled in Medicare. An optical shop that is not will bill the patient in full.

Most Advantage plans bundle a routine vision benefit: an annual eye exam and an allowance toward frames or contacts, usually every one or two years, through a contracted network. It is a real benefit and a common reason people choose these plans. As with dental, the things to verify are the allowance amount, the network, and whether your parent's existing eye doctor takes it.

Note that the medical coverage does not change. Cataract surgery, diabetic eye exams and macular degeneration treatment are covered under Advantage plans too, because plans must cover everything Original Medicare covers — though they may require prior authorization and an in-network surgeon.

1. 1.If your parent has diabetes, book the annual retinopathy exam. It is covered, it is preventive, and diabetic eye disease is silent until it is not.
2. 2.If they have a family history of glaucoma or fall into the other high-risk groups, claim the annual screening.
3. 3.If they have had cataract surgery in the past and never collected the covered pair of glasses, ask — families miss this constantly.
4. 4.If they are on an Advantage plan, find out whether this year's vision allowance has been used before it expires at the end of the plan year.
5. 5.If vision has changed suddenly, or there is pain, flashes, floaters or a curtain across the field of view, that is not a coverage question. That is an urgent appointment today.