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.