Eye Exams & Insurance: FAQS

Insurance coverage for eye exams can be a confusing topic. Get answers below to frequently asked questions.

FAQs

• If I don’t have a vision plan, may I get an eye exam?
  • Yes, comprehensive eye exams can be covered under any standard health insurance provided the appropriate copayment has been made and/or deductible met in addition to the following:
    • There is a medical diagnosis that relates to the eye, visual system and/or associated structures and is symptomatic, or has been previously diagnosed
    • You have a diagnosed systemic disorder with established risk to eye health
• If I have a complaint such as a red eye will my vision insurance cover it?
  • No, any health-related complaints will be considered a medical eye examination and typically covered under your regular health insurance.
• Are eye exams covered under health plans or vision plans?
  • Both. Eye care is a field of health care where both health insurance and vision insurance provides coverage. Typically, vision plans will cover annual or biannual preventative eye exams, along with some coverage toward glasses or contact lenses. Additional charges for glasses or contact lenses may apply based on your plan.
• Do I need a yearly exam if I see well?
  • Yes, a comprehensive eye exam does many things besides check vision. Detection of diabetes and high blood pressure as well as medical eye conditions such as macular degeneration and glaucoma are included in comprehensive exams. Because these conditions can be detected before symptoms appear, the eye exam is a preventive service.
• What about my children?
  • Medicaid and CHIP plans provide exams and glasses for children. In addition all individual health insurance and health plans for small businesses must cover eye exams and glasses annually. Many group health plans under the Affordable Care Act cover eye exams/glasses an annual basis.

Medicare

Once your deductible has been met, Medicare will cover an office visit or comprehensive exam for any medical complaint relating to the eye or visual system. Medicare also offers coverage for examinations if you have a diagnosed systemic disorder with established risk to eye health. In addition the majority of additional testing that may be required may be covered by Medicare with the appropriate diagnosis. Coverage may differ between individual plans.

Refraction (determining the prescription for glasses) and the glasses and/or contact lenses themselves are typically an out-of-pocket expense, or covered by a Medicare Advantage plan.

Medicare Advantage Plan

• What if I have a Medicare Advantage plan? Are there still out-of-pocket expenses?

• Yes, Medicare Advantage plans often offer additional benefits for materials. You may still be responsible for co-pay and/or premium based on your individual plan, in addition to items outside of your plan’s coverage.

Resources

These online resources can provide helpful information about eye health, protecting your vision and insurance questions.

• American Optometric Association
• thinkaboutyoureyes.com
• Vision Services: Medicare Fact Sheet
• medicaid.gov
• medicare.gov
• Centers for Medicare & Medicaid Services: Summary of Benefits and Coverage and Uniform Glossary

Learn more about what types of eye conditions and exams insurance covers. See examples.