Question: I need to get new glasses and they are so expensive. Does Medicare help pay for glasses?

Answer: The question of vision coverage is a really commonly asked question about Medicare.

Original Medicare is a health insurance product. This means that all of your coverage must be based on a medical problem or diagnosis. Most of us have problems with our vision due to age related vision problems.

Be sure to talk about your insurance coverage before you consent or decide on any procedure. You should not assume that any procedure is covered by your insurance. Ask about insurance coverage first, then schedule.

Remember that vision coverage is paid under Medicare Part B, so the usual deductible ($240) and co-pays (80/20) apply.

Medicare Part B will cover the appointment to see an Eye Doctor and the exam, like it would any specialists when there is a medical reason for seeing that specialist. Medicare requires that you see a participating Ophthalmologist or Optometrist. The optometrist is included in your coverage depending on your state (NY the answer is yes). In making your appointment, explain that you have Medicare and ask if they participate with Medicare and ask if Medicare will cover this appointment.

Medicare Part B does not include routine eye exams or for eye refractions at an appointment.

Medicare Part B will cover the eye exam for those with a medical diagnosis and also injuries and illnesses of the eye. These situations would include cataracts, glaucoma, diabetes, or injuries like damaged retina, eye infections, etc.

Medicare Part B covers your corrective lenses in limited situations (if you have had cataracts surgery for example.)

Medicare Part B covers Cataract Surgery. This surgery includes removal of the cloudy natural lens and often replaces this lens with a clear artificial lens. After you have cataract surgery your vision will have changed significantly, sometimes to the point of not needing glasses at all. If you do still need corrective lenses after your surgery, Medicare will pay for the lens for that eye. Medicare does NOT pay for the frames. This also requires that your chosen provider is an enrolled Medicare supplier/provider.

In some situations, individuals opt to have a corrective lens implanted during their cataract surgery. This upgraded lens is never covered by Original Medicare.

If you have a Medicare Advantage plan, (HMO, PPO, and PFFS plan) they may give you additional coverage for glasses. Remember these plans must give you at least the minimum that Medicare gives you, but they can give you more coverage. When making your appointment be sure to inform the office of your Medicare Advantage Plan Company and the name of the plan in which you are currently enrolled. Coverage and participation in these plans is different for each office.

Many of the Medicare Advantage Plans give you an allotment toward your glasses. This is sometimes $100 but can be as high as $300. That means if you get glasses, you can file a claim with your insurance provider, and they will pay you back their dollar amount. This $100 to $300 will certainly not pay for the glasses, but it will help to offset the cost for you. With a Medicare Advantage plan, be sure to call your Plan prior to getting your glasses. They may restrict who you go to (Provider Network), and what type of glasses/frame they will reimburse you for.

It is common to have employee/retiree plans that will cover glasses. Since many individuals come to Medicare from an employer plan, they are sometimes surprised by this perceived gap in coverage.

It is possible to purchase additional insurance plan for vision. These insurance products are usually relatively low cost and require you go to participating providers. You pay an additional premium for the plan, but if you want to have coverage for that routine (annual) vision exam and possibly help pay for your glasses, this may be a product you would like to purchase. These plans are usually cost effective as long as you go to a participating provider and purchase glasses/contacts that are included in the coverage of the plan.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.