...continued from Medicare and Medicaid Vision Benefits

Medicare Advantage (MA), Part C Plan and Vision Benefits

Medicare Advantage (MA) plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFS (Private Fee-for-Service plans), and Special Needs plans.

Medicare HMO is a group of health care providers who have contracted to serve Medicare policy holders at reduced rates. Policy holders opting for this health plan usually are permitted to receive health care only from HMO providers.

Medicare PPO is a network of healthcare providers organized by an insurance company to provide healthcare services to Medicare policy holders at a fixed rate below retail prices. Policy holders may opt to obtain their health care from out-of-network providers, but at higher cost.

Medicare PFS plan is a private health plan organization that has contracted with Medicare to provide health care services to Medicare policy holders. With this kind of plan, you can go to any provider who agrees to abide by the plan's regulations. And each time you visit a provider, you pay out-of-pocket the amount dictated by your health plan organization.

Medicare Special Needs plans cover policyholders confined to nursing homes, and who can receive both Medicare and Medicaid and/or who have qualified disabilities.

[Read more about private vision benefits and insurance plans]

A Medicare policy holder who opts for an MA plan may have access to additional vision care benefits. Vision benefits vary from plan to plan with respect to cost and coverage. In general, however, you can expect an MA vision benefit plan to cover the following:

• Routine eye exams including pupil dilation
• Eyeglass frames (once every 24 months)
• One pair of eyeglass lenses or contact lenses every 24 months

Should I Switch to an MA Medicare Plan To Receive
Extra Vision Benefits?

You should consider your options very carefully before switching from your existing Medicare plan to an MA plan. Before making this decision, ask yourself these questions:

• Which benefits will I lose if I leave my original Medicare plan? As an example, you may be asked with an MA plan to use specific kinds of medications as a way to reduce costs. Access to extra vision benefits may not be worth losing a medication you prefer.
• Which benefits will I gain by switching over to an MA plan? Eye exams are among preventive types of benefits that may be covered under an MA plan.
• Does the MA health plan that interests me have enough reputable service providers near where I live? It does you no good to have extra benefits if you can't access a provider. Also, you should decide how far you would be willing to travel if a network provider doesn't live near you.
• Would I be willing to wait for an appointment from a network provider? If your provider is extra busy, you might have to wait a while before you can get an appointment. Because you must use a provider within the network, your choices for a more immediate appointment may be limited.
• Who is on the network provider list? You may have a long-term relationship with a provider who you might have to give up, depending on the type of plan you choose.
• Are the network providers reputable, and is the plan itself user-friendly? Ask around to make sure the network providers listed have a good reputation in your community. Also, see if a quality assurance mechanism is in place for your plan and an easy-to-follow grievance procedure in case you disagree with any decisions made about your claim.

Again, make sure that the MA plan you consider won't cost you more out-of-pocket money than you can afford, even if you do receive extra vision benefits. For example, a Commonwealth Fund report from the non-profit health foundation in 2006 found evidence that MA policyholders in poor health pay more out-of-pocket for health services than they would under the original Medicare Part A and Part B plan.

For more details about Medicare plans, call the Medicare hotline at 1-800-633-4227.

Page 3 of 3: Medicaid and Vision Benefits

[Page updated April 2009]