Glaucoma is a progressive group of eye diseases that damage the optic nerve, often due to elevated pressure within the eye. This damage results in irreversible vision loss. Because the condition frequently presents with no early symptoms, it is often called the “silent thief of sight.” Understanding if and how Medicare covers preventive testing for this serious condition is important for maintaining eye health, as early detection through regular screening is a primary defense against disease progression.
Eligibility and Frequency Under Standard Medicare
Medicare Part B, which covers outpatient medical services, provides coverage for glaucoma screening, but only for beneficiaries classified as “high risk.” This coverage is considered a preventive service and is available once every 12 months for those who qualify.
Medicare covers the annual screening for beneficiaries who meet specific high-risk criteria, ensuring those most likely to benefit receive regular monitoring. These criteria include:
- A diagnosis of diabetes mellitus.
- A direct family history of glaucoma (parent or sibling).
- African Americans aged 50 and older.
- Hispanic Americans aged 65 or older.
The covered screening is a comprehensive examination billed to Medicare using specific procedure codes (HCPCS G0117 or G0118). The testing must be furnished or supervised by an ophthalmologist or an optometrist legally authorized to perform the service in the state. This examination includes a dilated eye exam and a measurement of intraocular pressure, a common indicator of glaucoma risk.
The screening also requires a detailed inspection of the optic nerve, performed through either a direct ophthalmoscopic or a slit-lamp biomicroscopic examination. This visual assessment helps the provider look for physical signs of nerve damage indicating early stages of glaucoma. The provider must document the patient’s high-risk status using the appropriate screening diagnosis code for the claim to be covered.
Patient Costs and Out-of-Pocket Expenses
Although the annual glaucoma screening is a preventive service, it is subject to the standard cost-sharing rules of Original Medicare Part B, unlike some other preventive benefits. The beneficiary must first meet the annual Part B deductible before Medicare pays its share. This means the initial out-of-pocket expense varies depending on where a person is in their benefit year.
Once the yearly deductible has been satisfied, Medicare Part B covers 80% of the Medicare-approved amount for the screening service. The patient is responsible for the remaining 20% coinsurance of the approved cost.
If the screening is performed in a hospital outpatient setting instead of a doctor’s office, the patient may also incur a hospital copayment. This additional facility fee increases the overall out-of-pocket cost beyond the physician’s coinsurance.
Many Medicare beneficiaries purchase supplemental insurance, known as Medigap, to manage these financial responsibilities. Medigap policies cover the coinsurance and deductible amounts that Original Medicare does not pay. This supplemental coverage can significantly reduce or eliminate the 20% coinsurance due for the annual glaucoma screening.
Coverage Through Medicare Advantage Plans
For beneficiaries enrolled in a Medicare Advantage Plan (Part C), the coverage structure differs from Original Medicare but must meet certain minimum requirements. By law, a Part C plan must cover all services included in Original Medicare Part A and Part B. Therefore, the plan must provide the annual high-risk glaucoma screening benefit, ensuring qualified individuals receive coverage regardless of their plan choice.
Medicare Advantage plans often offer additional, broader coverage that goes beyond the minimum Part B requirements. Many Part C plans include routine vision benefits that cover comprehensive eye exams for all members, even those who do not meet the Part B high-risk criteria. These benefits may include screenings that identify early signs of glaucoma more often than the once-per-year rule.
The patient’s financial responsibility changes under a Medicare Advantage plan, moving away from the Part B model of deductibles and coinsurance. Part C plans typically use set copayments—a fixed dollar amount the patient pays for the screening. This copayment amount varies widely between different plans.
Medicare Advantage plans, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), often use networks of contracted providers. To receive the highest benefits and lowest costs, the patient must typically see an eye doctor within the plan’s network. This network restriction is a key difference from Original Medicare.