Vision Benefits of Medicare Advantage Plans
(Medicare Part C)
Medicare Advantage Plans Medicare-approved health plans run by private insurance companies (also called "Medicare Part C" or "MA Plans") include the following:
Health Maintenance Organization Plans. A health maintenance organization (HMO) is a group of health care providers who have contracted to serve Medicare policyholders at reduced rates. Medicare-eligible individuals opting for an HMO plan usually are permitted to receive health care only from HMO providers.
Preferred Provider Organization Plans. A preferred provider organization (PPO) is a network of health care providers organized by an insurance company to provide services to Medicare policyholders at a fixed rate below retail prices. Enrollees in a PPO plan usually can opt to obtain their health care from out-of-network providers, but at higher cost.
Private Fee-for-Service Plans. A private fee-for-service (PFFS) plan generally allows Medicare-eligible enrollees to go to any health care provider who agrees to abide by the plan's regulations. Each time you visit a provider, you pay out-of-pocket the amount dictated by the PFFS plan.
Special Needs Plans. A Medicare-approved Special Needs Plan (SNP) must provide the benefits of Medicare Parts A and B, as well as Medicare Prescription Drug Coverage (Part D). Membership in a Special Needs Plan is limited to the following groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home; 2) people who are eligible for both Medicare and Medicaid; or 3) people who have specific chronic or disabling conditions (such as diabetes). SNPs may further limit membership in other ways.
[Read more about private insurance plans and provider networks.]
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A Medicare-eligible individual who opts for a Medicare Advantage Plan may have access to vision care benefits beyond what is available with Medicare Parts A and B. Vision benefits vary from plan to plan with respect to cost and coverage. In general, however, you can expect an MA Plan to offer the following vision benefits:
- 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 a Medicare Advantage Plan To Receive
Extra Vision Benefits?
You should consider your options very carefully before switching from original Medicare (Parts A and B) to a Medicare Advantage 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.
Also, make sure that the Medicare Advantage plan won't cost you more out-of-pocket money than you can afford, even if you do receive extra vision benefits. In some cases, choosing an MA plan may cost more in higher premiums, co-payments and other expenses than you save in added services provided.
For more details about Medicare plans and coverage including Medicare Advantage and Medigap insurance policies visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227).
Page 3 of 3: Medicaid and Vision Benefits
[Page updated May 2014]