Does Medicare Cover Ophthalmologists?

An ophthalmologist is a medical expert who specializes in diagnosing eye diseases and treating or operating on them. In other words, they are responsible for taking care of your vision, especially more serious eye issues.

So a common question many people have is, “does Medicare cover ophthalmologists?” In this article, we answer that question in clear, plain English. You will also find the average costs of eye surgeries and other helpful info.

Does Medicare Cover Ophthalmologists?

The short answer is yes; Medicare will cover the cost of an ophthalmologist visit. But not 100% of the time. As is often the case with Medicare, you must meet certain conditions in order for Medicare to pay for your ophthalmologist visits. Below we look at what these are so you know what to expect.

Original Medicare

Original Medicare (Medicare Part A and Part B) provides coverage for ophthalmologists.

Despite the fact that Original Medicare does not provide coverage for many routine eye services, they provide coverage for ophthalmologist services such as eye surgery if it is considered medically necessary. One such surgery that Original Medicare covers is cataract surgery.

Medicare Part A provides coverage for eye surgeries performed in an inpatient setting. On the other hand, Medicare Part B provides coverage for eye surgeries that take place in an outpatient setting.

Most of the time Medicare Part B provides coverage for cataract surgery as it is considered medically necessary. Medicare Part B also provides coverage for preoperative and postoperative eye exams for your cataract surgery. Other than that, Medicare Part B provides coverage for the following services related to your cataract surgery:

The implantation of intraocular lens (IOL). Medicare Part B will not provide coverage for all types of IOL.
Purchase of one pair of corrective eyeglasses. Medicare Part B will provide coverage for another pair of eyeglasses if you undergo cataract removal surgery for your other eye later in your life.

Not all types of eye surgeries are covered by Original Medicare. Surgeries such as LASIK eye surgery are not covered by Original Medicare as they are not considered medically necessary.

Original Medicare also provides coverage for vision care if you have diabetes. They cover eye exams once a year to check if you have any diabetes-related eye problems. They also provide coverage for glaucoma treatment and considers you at high risk for the condition if you are/have:

Diabetes
Family history of glaucoma
African American at the age of 50 or above
Hispanic American at the age of 65 or above

Part C Coverage for Ophthalmologists

Medicare Advantage plans (Medicare Part C) also provide coverage for ophthalmologists. They cover everything Original Medicare covers, as well as some additional benefits. However, exactly what it covers and your out-of-pocket costs will vary depending on the specifics of your plan. Medicare Part C also provides coverage for routine vision services.

How Much Does It Cost To Visit An Ophthalmologist?

Visiting an ophthalmologist can cost you from $45 to $75. Cataract surgery can cost between $3,000 and $6,000.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.