Vision for Seniors

  1. Vision Coverage with Original Medicare

Generally, with just Original Medicare, there shouldn’t be much of an expectation about vision coverage provided – several visual procedures and products will require additional insurance to acquire past your Medicare A and B. For any sort of vision help with Medicare Part A, you’ll need to have a serious medical problem – essentially, this means you won’t be covered by your Medicare Part A unless the eye damage is possibly related to a serious medical injury, especially one that is treated in a hospital. In select circumstances however, your Medicare Part B may be flexible enough to offer coverage regarding a few vision-oriented services; though typically only for those who would need the help medically, it may still be possible for yourself if:

  • You’ve undergone a surgical procedure to fix or alter your eye – removing a cataract or replacing your eye’s natural lens with an artificial replicate may apply to this reason.
  • You medically require an eye exam to help survey or diagnose a potentially worse optical issue – thankfully, if your situation applies here and your exam was completely necessary to complete for possible prevention’s sake, Medicare coverage will be in effect (even if nothing is found further.)
  • You’ve got a high risk for glaucoma – in these cases, Medicare may offer you a state-approved yearly screening for glaucoma, but only most likely if you’re a diabetic or have a family history of glaucoma.
  • You need cataract surgery – your cataract surgery, including standard-frame glasses needed afterwards, can be covered by your Original Medicare.
  • You need an eye protheses, or “fake eye,” because of one’s removal – Medicare will also offer coverage when looking to have the eye cleaned, polished, as well as resized (but only once.)
  • You’ve got Age-Related Macular Degeneration – for those who may be losing their vision through degenerative properties, Medicare may pay for both the drugs and doctors needed to continue regular care of your eyes.

Medicare Part B will not cover routine eye exams, eyeglasses, or contact lenses for individuals without significant reason, such as the case with cataract surgery – standard enrollees must seek out Medicare alternatives, like a Part C plan, or an additional stand-alone policy in order to receive any cost-sharing towards those needs. Recognize that coverage for vision, especially through Original Medicare, is primarily on a very need to have basis and generally shouldn’t be considered “applicable” to yourself when first enrolling unless sure; remember, you’ll still be very likely inclined to pay about the same co-insurances as many other Part B services when making use of this coverage.

  1. Vision Coverage with a Medigap Supplement Plan

Plainly put, there is no vision coverage provided by a Medigap plan – and there’s a clear reason for that. You see, Medigap plans aren’t actually usually seeking to provide additional benefits to that of your Original Medicare, but rather, they want to provide for the gaps where you would be paying out-of-pocket for coverage you’re already receiving; basically, this amounts to your Medigap “offering” the same coverage you may already have through Original Medicare, but while paying big portions of the 20% you owe after many different procedures.

Unfortunately, this means that no matter what supplement policy you choose, you cannot expect more coverage than what you’re already entitled to

  • You will still not have coverage for routine eye exams, glasses, or contacts.

However, based on your supplement policy’s plan, you may pay a much lesser amount for your Original Medicare vision services, like glaucoma screenings, cataract surgeries, and so on. This is because most of these services – like much other Part B coverage – is divided into 2 percentages: one for you to pay (20%) and one for Medicare to pay (80%.) While Medicare pays 80% of these services, your 20% can be further reduced by your supplement policy, making vision coverage ultimately more affordable than through just Original Medicare.

  1. Vision Coverage with a Medicare Part C Advantage Plan

Enrollment into a Medicare Part C advantage plan can give you much more than you’ve gotten than with your Original Medicare – remember, through incentives like additional vision coverage, an advantage plan can properly get you the ancillary help you may need (and may not be getting through Medicare now.) Held to a required standard that all plans must have at least equivalent coverage to that of Original Medicare’s, all advantage plans come equipped with the same considerations you’ve become accustomed to – this includes the more specific coverage like glaucoma screenings and cataract surgery – but likely at a different cost.

Depending on the layout of the healthcare provider’s plan, you may be charged a coinsurance for services (much like your Original Medicare) or, instead, a copay. Additional services common to advantage plans will depend on the provider, as well as the specific plan, but here a few common occurrences:

  • You may be covered for routine eye exams.
  • You may be covered for eyeglasses.
  • You may be covered for contact lenses.
  • You may be covered for the fitting for correct frames and contacts.
  • You may be covered for annual diabetic exams.
  • You may be covered for further preventative or diagnostic vision treatment.

Provisions for things like glasses and contact lenses are typically offered in a manner most preferable for the healthcare provider – this might include setting a maximum coverage for the enrollee to purchase a choice of their own (usually from an approved vendor,) or maybe offering their own selection from which you’ll need to choose from for coverage. 

Limitations as such can greatly affect your cost expectations – those who purchase a premium selection, for example, may not fully consider their maximum coverage in correlation to the quality of their choice and will create an unintended out-of-pocket expenditure; while those who are only given a limited pre-made lot to choose from may have to settle for their options, or risk full out-of-pocket cost. Remember, an advantage plan is the sum of many parts – it is greatly recommended to weigh the requirements, coverage, and costs of your plan’s vision benefit against its other portions, such as the plan’s premium, its dental coverage, hearing coverage, deductible, drug coverage, and so on. 

If we compare even just a few providers, the differences between plans can become much more apparent – especially with slight alterations to the provided maximum coverage. Here’s a short look of some provider’s plans, using a Houston, Texas zip-code for example, including coverage offered under separate networks (like HMOs vs PPOs) and even for Special Needs Plans:

Humana

  • Humana Gold Plus H0028-038 (HMO):
  1. Monthly Plan Premium – $0
  2. Medicare Covered Vision Services – $40 copay.
  3. Diabetic eye exam, glaucoma screening, and any eyewear post-cataract surgery is all free.
  4. Routine vision exam and refraction (1 per year) is free.
  5. Eyewear is covered –
    1.  $100 maximum coverage for eyeglasses or contact lenses
  1. HumanaChoice H5216-128 (PPO):
    • Monthly Plan Premium – $0
    • Medicare Covered Vision Services – $35 copay in-network / 30% of the cost out-of-network.
    • Diabetic eye exam, glaucoma screening, and any eyewear post-cataract surgery is all free in network; out-of-network, they are 30% of the cost.
    • Routine vision exam and refraction (1 per year) is covered – 
      1.  $75 maximum coverage
    • Eyewear is covered – 
      1.  $100 maximum coverage for eyeglasses or contact lenses
  1. HumanaChoice R4182-001 (Regional PPO):
    • Monthly Plan Premium – $0
    • Medicare Covered Vision Services – $35 copay in-network / 30% of the cost out-of-network.
    • Diabetic eye exam and glaucoma screening are free in-network; out-of-network, they are 30% of the cost.
    • Eyewear post-cataract surgery is free.
    • Routine vision exam and refraction (1 per year) is covered – 
      1.  $75 maximum coverage
    • Eyewear is covered – 
      1.  $200 maximum coverage for eyeglasses or contact lenses
  1. Humana Gold Choice H8145-126 (PFFS):
    • Monthly Plan Premium – $50
    • Medicare Covered Vision Services – $45 copay in-network / $50 copay out-of-network.
    • Diabetic eye exam is free in-network; out-of-network, it is a $50 copay.
    • Glaucoma screening and eyewear post-cataract surgery are free in-network; out-of-network, they are 30% of the cost.
    • Eyewear post-cataract surgery is free.
    • Routine vision exam and refraction (1 per year) is covered – 
      1.  $130 maximum coverage
    • Eyewear, including eyeglasses and contact lenses, is not covered.
  1. Humana Gold Plus SNP-DE H0028-033 (HMO SNP):
    • Monthly Plan Premium – $0
    • Medicare Covered Vision Services are free.
    • Diabetic eye exam, glaucoma screening, and any eyewear post-cataract surgery is all free.
    • Routine vision exam and refraction (1 per year) is free.
    • Eyewear is covered – 
      1.  $200 maximum coverage for eyeglasses or contact lenses. 

Blue Cross Blue Shield

  • Blue Cross Medicare Advantage Basic (HMO):
  1. Monthly Plan Premium – $0
  2. Exam to diagnose and treat eye conditions, including glaucoma screening, and any eyewear post-cataract surgery is all free.
  3. Routine vision exam (1 per year) is free.
  4. Eyewear is covered – 
    1. Contact lenses and eyeglass frames are both a $0 copay.
    2. Eyeglasses lenses (1 pair every 2 years) are a $25 copay.
    3.  $250 maximum coverage (every 2 years) for eyeglasses and contact lenses.
  • Blue Cross Medicare Advantage Choice Plus (PPO):
  1. Monthly Plan Premium – $20
  2. Exam to diagnose and treat eye conditions, including glaucoma screening, and any eyewear post-cataract surgery is all free in-network; out-of-network, it is 50% of the costs.
  3. Routine vision exam is free in-network; out-of-network, there is a $40 coverage limited provided.
  4. Eyewear, including eyeglasses and contact lenses, is not covered.

Wellcare

  • WellCare TexanPlus Classic (HMO):
  1. Monthly Plan Premium – $0
  2. Medicare eye exams, glaucoma screenings, and any Medicare covered eyewear is all free.
  3. Routine vision exam and refraction (1 per year) is free.
  4. Eyewear is covered – 
    1.  $100 maximum coverage for eyeglasses or contact lenses.
  • WellCare Value (HMO-POS):
  1. Monthly Plan Premium – $0
  2. Medicare-covered diabetes exam is free in-network – all other Medicare-covered exams are a $30 copay in-network; out-of-network, these are all 35% of the cost.
  3. Medicare-covered eyewear is free in-network; out-of-network, it is 35% of the cost.
  4. Routine vision exam and refraction (1 per year) is free in-network; out-of-network, there is no coverage.
  5. Eyewear is covered – 
    1.  $100 maximum coverage for eyeglasses or contact lenses in-network; there is no coverage for eyewear out-of-network.
  • WellCare Liberty (HMO SNP):
  1. Monthly Plan Premium – $0
  2. Medicare eye exams, including Medicare-covered diabetes exams and glaucoma screenings, as well as any Medicare covered eyewear is all free.
  3. Routine vision exam and refraction (1 per year) is free.
  4. Eyewear is covered – 
    1.  $300 maximum coverage for 2 pairs of eyeglasses or contact lenses.
    2. If you select 2 pairs, they must be chosen at the same time.
  1. Vision Coverage with Stand-Alone Vision Plans

The route of a separate vision plan entirely may end up being your most optimal – whether it be the case of wanting to get more out of your Original Medicare, or trying to take the costs you save from a Medigap policy to apply elsewhere, the security of a stand-alone vision insurance can provide comfort when thinking about the ongoing health of your eyes. By committing to a plan, you can have all the benefits you’re not receiving currently and more, all while not feeling forced to pit your amount of vision coverage against other benefits; but, how does separate vision insurance work from any other insurance?

Thankfully, it’s not much different than your expectation – you’ll be likely charged a monthly premium, ranging from about $15 to $20 and up depending on your need for coverage, which will be a guide for just what coverage will be available and how your plan will decide to serve you. Individual costs, like copays or coinsurances, are very likely, but are generally balanced in correlation to your premium – the higher the premium, the less you’ll have to pay for individual services and products like exams, eyeglasses, contacts, and so on.

A separate vision plan would usually be in conjunction with your Original Medicare or otherwise, so most serious optical issues will not be covered through your stand-alone plan; however, you’ll likely be given reduced costs for:

  • Your basic preventative care, including eye exams and tests needed to routinely check the eyes.
  • The eyeglass lenses and frames necessary to building a perfect pair.
  • Contact lenses.
  • And protective selections, such as more durable frame materials and scratch-resistant coatings.

By selecting a proper plan, you can consider your needs quickly and efficiently – remember, plans may have rules like network restriction for costs, limited eligible vendors, and waiting periods; make a note of the factors and competitive options in your area and feel free to regularly compare. If you may be unable to enroll into a separate vision policy entirely, vision discount plans, much like dental discount plans, may also be available to help reduce costs at a limited selection of providers, only requiring a small membership fee to participate.

References:

https://www.ehealthmedicare.com/medicare-coverage-articles/medicare-vision-benefits/
https://www.ehealthmedicare.com/faq/what-is-the-medicare-coverage-for-eye-care-and-eyeglasses/
https://www.ehealthinsurance.com/medicare/coverage-all/does-medicare-cover-vision
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/humana/2019/H0028_038_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/humanainsurancecompany/2019/H5216_128_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/humanainsurancecompany/2019/R4182_001_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/humana/2019/H0028_033_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/humanainsurancecompany/2019/H8145_126_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/hcscinsuranceservicescompany/2019/H1666_006_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/bluecrossandblueshieldoftexas/2019/H8133_001_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/selectcareoftexasinc/2019/H4506_003_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/todaysoptionsoftexasinc/2019/H0174_005_000_SOB.pdf
https://static.ehealthmedicareplans.com/ehealthinsurance/benefits/ma/todaysoptionsoftexasinc/2019/H0174_006_000_SOB.pdf