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Medicare coverage of glasses after cataract surgery

October 12th, 2010 · 15 Comments · Eyewear, Ocular Disease

The Medicare program covers for eyeglasses following cataract surgery.  An explanation of the billing can be fraught with questions due to the partial coverage Medicare offers and the number of options available with new eyewear today.  Here are the facts on Medicare coverage.

The Medicare Part B deductible for the year is $140 (2012).  This can vary each year.

Medicare Part B coverage applies for one pair of glasses following cataract surgery.

Your claim is filled as a Durable Medical Equipment Regional Carrier (DMERC) claim which is a different branch of Medicare than the processor used for office and surgical visits.

Standard Frames are covered up to the allowable of ($60.72 = 2010 allowed rate) : of this Medicare pays 80% after the deductible is met.  The covered amount can change every 3 months depending on Medicare funding and policy changes.

Deluxe Frames are frames that cost more than the Standard Frame coverage.  For example if a frame selected costs $80.00 then the deluxe frame fee would be ($80.00 – $60.72) = $19.28.  Medicare does not cover this portion of the amount and the patient is due this amount.  The jargon Medicare uses is that this item is “noncovered.”  Medicare gives you the freedom to choose any frame you desire that your eyewear provider can provide.  The Medicare deluxe frame policy allows patients to choose from any frame and have part of their Medicare coverage help defray the expense of these frames.

Lenses for a standard bifocal or a single vision lens is covered.  The covered amount varies based on the prescription strength.  Medicare pays 80% of this after the deductable is met.

Options such as trifocals, progressive / lineless multifocals and lens options such as tints, photochromatic (e.g Transitions, Photogrey Extra) are not covered.  Scratch resistant coatings, anti-reflection coatings, and special materials such as high-index or polycarbonate are not covered either.  A patient can opt to purchase these options at their expense.

Refractions are the vision-specific tests required to determine a spectacle prescription.  This service is not covered by Medicare and a fee for this service as a test is in addition to a Medicare covered eye disease visit.

If you have insurance that is supplemental to your Medicare (also known as Medigap), then your claim is usually automatically forwarded electronically for review and payment after Medicare processes the claim. They may cover the 20% of the costs that Medicare doesn’t cover.  They will not cover the “noncovered” expenses such as deluxe frames and lens options.

Future eyewear purchases are not covered after the first pair.  An exception to this rule is for people that did not receive an intraocular lens during their cataract surgery.  They however end up with heavy and thick lenses to wear for the rest of their life.  Over 99% of patients get intraocular lenses which avoids this inconvenience and offers more natural vision.

Medicare replacement programs such as Medicare Advantage may have coverages that differ from the example given above.

The specific policy by Medicare can be researched at:  https://questions.medicare.gov/app/answers/detail/a_id/840/~/what-is-the-medicare-coverage-for-eye-care-and-eyeglasses%3F

Update – January 2013

Medicare began a requirement for all DMERC providers to pay an annual $500 fee to provide durable medical equipment (such as glasses after cataract surgery).  This policy was developed as a way to try to curb the fraudulent billing by fly-by-night home medical equipment providers who start up, bill hundreds of thousands of dollars in false claims then shut down before the Medicare fraud units respond.  The problem is that in eyecare this practice never existed the way it did for home medical equipment.  Hundreds of providers have quit being a DMERC provider including our office.  It became a losing proposition to pay an annual fee when reimbursements are wholesale only.

We won’t be able to answer “how to” questions on claim submissions or “how much” as we are no longer providers until Medicare reverses this policy.


15 Comments so far ↓

  • mary weiserNo Gravatar

    How do I file claim for reimbursement of glasses after cataract surgery? Thanks Mary

  • Dr Doug CookNo Gravatar

    If your provider did not file a claim on your behalf consider this: http://www.medicare.gov/navigation/medicare-basics/understanding-claims/how-to-file-a-claim.aspx

  • Jacqueline A. IacolettiNo Gravatar

    I need to file a claim for my new lenses . I had
    cataract surgery August 21, 2012 and September
    21, 2012. I used the same frame I had.

  • Jacqueline A. IacolettiNo Gravatar

    I had cataract surgery August 21, 2012 and
    September 4, 2012. I need to file a claim
    for new glasses.

  • Dr Doug CookNo Gravatar

    The provider of eyewear can submit a claim if they are a Medicare Durable Medical Goods (DMERC) provider. Ask your doctor for help.

  • Cindy WicoxNo Gravatar

    what is the time limit to file for Cataract glasses.

  • Dr Doug CookNo Gravatar

    One year.

  • Irma A LespasioNo Gravatar

    I already paid for the glasses because my optician is not connected to Medicare. Therefore, I would like to be reimbursed by Medicare. How do I go about it. Can you supply me with a form for this purpose. Thank You

  • Dr Doug CookNo Gravatar

    I’m afraid you made a mistake that will be difficult to fix. You should have asked if your supplier was a Medicare DMERC approved supplier. They are required to fill a claim for you. The standard form is an CMS-1500 form and the procedure to fill it out may differ depending on the region where you live. Most providers fill this electronically now using special services available availalable to Medicare “vendors.”

    The best fix would be to 1. Research which Medicare DMERC carrier covers your state. 2. Submit your printed receipt. You will need your Surgery date(s), eye, surgeon in addition to the itemized receipt detailing lens and frame cost. Even with this your chances or reimbursement are slim on your own.

    We just quit being a Medicare vendor. Many Ophthalmologists / Optometrists / Opticians are quitting as well across the USA. The reason is that Medicare now charges $500 yearly fee to file these claims. As Medicare pays wholesale cost only, it’s a losing proposition for a vendor to continue to offer Medicare filing services.

  • Rosemary BunnNo Gravatar

    I purchased 2 pairs of glasses in May by June I felt that my vision had changed. I was told by cataracts were ready to be removed. Both have been removed and I now have new glasses. My questions is, I kept the same frames and added trifocals which I just found out on my own that Medicare doesn’t pay for trifocals. I would’ve been content with bifocals. This added expense is putting a burden on my finances. Should I have been charged twice with in 6 months for glasses or should there have been some compensation?

  • Dr Doug CookNo Gravatar

    It is always sound to try the least invasive and safest treatment first before proceeding up in risk in the treatment options. For example, risk increases for complications in this general order: topical medication, oral medication, injectable medication, laser or emitted energy, minor surgery, major surgery. A pair of eyeglasses if successful offers the least risk when compared to this risk scale – especially since cataracts produce prescription changes. If an eyewear Rx can delay cataract surgery until the benefits outweigh the risks I discuss this with a patient who usually prefers to try the Rx. We have gotten so proficient at eyewear prescription design that guarantees are often presented where in general medical care or surgery no guarantee can or should be offered – often by state law.

    A mindset can develop that blames something other than the cataract which may have been the root cause. When a cataract exists, some component of the blur is due to a prescription change while some will be due to the cataract. A new eyewear’s success or not isn’t known until it is tried. It appears with the information given that this was the intent and it’s good policy – it would also stand to reason that the eyewear would not be subject to a guarantee due to the existing medical condition.

    As far as the trifocal versus bifocal question, it’s important to relay your desires during the design of the eyewear as to choose a bifocal or a trifocal. The DMERC supplier should have told you their would be an upcharge not covered by medicare and have an Advance Beneficiary Notice of Noncoverage on file.

  • Bill DalyNo Gravatar

    Me too… Visionworks #329 Jacksonville Fla. mad my glasses on 10/17/2013. They did not contact MC. I think it was because the total charge was $951.91 but because I was 91 years old they discounted this (outrageous charge) 90 %. This brought the out of pocket charge to $ 95.99. My question ? does Medicare help me with my out of pocket cost??

  • Dr Doug CookNo Gravatar

    Call your eyewear provider – they have the most information that could help you.

  • Paul DavidsonNo Gravatar

    Just in case anyone needs to fill out a Form CMS-1500, I found a blank form here http://goo.gl/zdF3Ci. This site PDFfiller also has some tutorials how to fill it out and a few related forms that you might find useful.

  • ChrisNo Gravatar

    We were in the process with getting on board with DMERC and they let our application go without telling us of further paperwork that needed to be filed… thus $500 out the window. They want another $500 to start again. I think not.

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