medi-cal & medicare vision benefits
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To provide the Disabled, Elderly, Low Income, Veterans, and Schools with high quality lenses and frame options one would receive at a High End Opticianry or Optometric Practice. What’s the difference between what patients will receive? All patients will be properly fitted by a Registered Spectacle Lens Dispenser and ABO Certified Optician who specializes in complex optical fitments. Seeing your Optometrist is the first step to ensuring you're on the right path to obtaining better vision. Seeing a Licensed Optician is the second step to ensuring that prescription is filled accurately.
Posted by Covered CA.
Vision benefits are covered for those with full-scope Medi-Cal benefits. For information about Medi-Cal eligibility, individuals can contact their county human services agency. Vision benefits are described below.
**Routine Eye Exam Once Every 24 Months, Diabetic patients may qualify for an exam every year. **
All Medi-Cal members are eligible for a routine eye exam, which checks the health of the eyes and tests for an eyeglass prescription (refraction).
Only members under 21 years old and residents of a nursing home receive coverage for eyeglasses** (basic frames and basic lenses (plastic) once every 2 years.
**Please See Material Benefits Below
Contact lens testing may be covered if the use of eyeglasses is not possible due to eye disease or condition.
Low-vision testing is available for those with vision impairment that is not correctable by standard glasses, contact lenses, medicine or surgery and that interferes with a person’s ability to perform everyday activities (e.g., age-related macular degeneration).
Artificial-eye services and materials are available for those individuals who have lost an eye or eyes to disease or injury.
Finding a Vision Provider
Contact a Medi-Cal provider directly for an appointment. For a list of vision providers, visit the online directory at the Find a Vision Care Provider page on the California Department of Health Care Services (DHCS) website. For other vision program questions, individuals may contact DHCS’s Vision Services Branch at email@example.com.
Posted by eHealthmedicare
Generally, Original Medicare does not cover routine eyeglasses or contact lenses. However, following cataract surgery that implants an intraocular lens, Medicare Part B helps pay for corrective lenses; one pair of eyeglasses or one set of contact lenses provided by an ophthalmologist.
Post-cataract services provided by an optometrist may be covered, if the optometrist is licensed to provide this service in your state, and:
- Medicare will pay only for standard frames.
- Eyeglasses and contact lenses are covered even if you had the surgery before you had Medicare.
- Both eye lenses may be covered even if you had your cataract surgery on one eye only.
A prescription order signed by your doctor (ophthalmologist or optometrist) must be on file with the supplier. Suppliers must be enrolled in Medicare and must meet strict standards to qualify for a Medicare supplier number. Medicare won’t pay your claim if your supplier doesn’t have a number, even if your supplier is a large chain or department store that sells more than just durable medical equipment (DME).
After each cataract surgery with an intraocular lens, you pay 20% of Medicare-approved amounts for one pair of eyeglasses or one set of contact lenses, after the Part B deductible, if applicable.
Medicare will only reimburse or pay for the standard eyeglass frame amount. You pay an additional cost for upgraded frames.
For more information about Medicare eye care, you may call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week.
Note: Ask if the supplier is a participating supplier in the Medicare program before you get durable medical equipment. If the supplier is a participating supplier, it must accept assignment. If the supplier is enrolled in Medicare but isn’t “participating,” it has the option to accept assignment.
If the supplier isn’t enrolled in Medicare, Medicare won’t pay your claim.
Medicare Part B covers a glaucoma screening test once every 12 months for people at high risk for glaucoma. This includes people with diabetes, a family history of glaucoma, African Americans who are age 50 or older, and Hispanic Americans who are age 65 or older. The screening must be done or supervised by an eye doctor who is legally allowed to do this service in your state.
You pay 20% of Medicare-approved amounts, and the Part B deductible applies.
ROUTINE EYE EXAMS
Routine eye exams are not covered by Medicare, including eye refractions. However, some preventive eye tests and screenings, such as glaucoma screening and treatment of macular degeneration, are covered.
You pay 100% out-of-pocket under Original Medicare for routine eye exams.
TREATMENT OF MACULAR DEGENERATION
Medicare Part B will cover certain diagnostic tests and treatment of diseases and conditions of the eye, which include treatment with certain injected drugs. Some people with age-related macular degeneration (AMD) are covered by Medicare. You would be responsible for 20% of Medicare-approved amounts for diagnosis and treatment of diseases and conditions of the eye after the Part B deductible is applied.
Eye prostheses are covered for patients with absence or shrinkage of an eye due to birth defect, trauma or surgical removal. Medicare covers polishing and of the artificial eye, and typically covers replacement every five years.
You pay 20% of Medicare-approved amounts after the Part B deductible is applied.
MEDICARE ADVANTAGE PLANS AND VISION COVERAGE
While Original Medicare coverage of routine vision care is limited, some Medicare Advantage plans may include additional vision benefits. Medicare Advantage plans are required to provide at least the same level of coverage as Medicare Part A and Part B, but many plans also cover additional benefits that go beyond Original Medicare, which may include routine dental or eye care.
Under a Medicare Advantage plan, vision benefits may include:
- Preventive eye exams covered under Original Medicare
- Routine eye exams
- Eyeglasses (frames and lenses)
- Contact lenses
Keep in mind that the specific benefits may vary, depending on the Medicare Advantage plans available in your service area. For more information, check with the individual health plan you’re considering. If you’d like help finding a Medicare Advantage plan that includes vision benefits, you can visit Medicare.gov or call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week (TTY users, call 1-877-486-2048. You can also contact eHealth to speak with a licensed insurance agent about your Medicare plan options.
|Single Vision||$35||(Copay for Lenses + Uncovered Amount)|
|Bifocal||$95||(Copay for Lenses + Uncovered Amount)|
|Trifocal||$105||(Copay for Lenses + Uncovered Amount)|
|Progressives||$120||(Copay for Lenses + Uncovered Amount)|
|Standard||$25||$120 Frame Allowance|
|Deluxe (Premium Eyewear)||$50||$140 Frame Allowance + 20% off Overage|
Listed below is the full Billing Breakdown. U&C refer to normal charges without any Benefit Coverage. If you have any questions about benefits, please contact us via email at firstname.lastname@example.org
|Description||CPT Code (HCPCS)||U&C||Benefit|
|Lenses, Single Vision (CR39)||V2100-V2199||99.00||99.00||35.00||0.00||35.00|
|HD Lenses, Single Vision (Trivex) with AR (C)||V2100-V2199, V2750||239.00, 89.00||118.00||35.00||76.00||134.00||169.00|
|HD Lenses, Single Vision (Hi-Index 1.66) with AR (C)||V2100-V2199,|
|Lenses, Bifocal (CR39)||V2200-V2299||159.00||99.00||35.00||60.00||95.00|
|Progressive Upgrade (N)||V2781||320.00||50.00||0.00||270.00||270.00|
|Progressive Upgrade (O)||V2781||260.00||50.00||0.00||210.00||210.00|
|Progressive Upgrade (J)||V2781||170.00||50.00||0.00||120.00||120.00|
|Lenses, Trifocal (CR39)||V2300-V2399||169.00||99.00||35.00||70.00||105.00|
|More Options are Available Upon Request|
|Tint, photochromatic, per lens, Single Vision||V2744||100.00||30.00||70.00||70.00|
|Tint, photochromatic, per lens, Multifocal||V2744||120.00||30.00||90.00||90.00|
|Anti-Reflective Coating (C)||V2750||89.00||19.00||70.00||70.00|
|Anti-Reflective Coating (D)||V2750||169.00||19.00||80.00||30.00||40.00||120.00|
|Frame, Deluxe||V2025||389.00||140.00||50.00||20% discount off overage||199.20||249.20|
|Assorted Contact Lenses||V2500-V2599||10% off minimum 3 month supply|
- Medical or Medicare Insurance Card
- State ID or Driver's License
- Valid Spectacle or Contact Lens Prescription
Please refer to your benefit coverage below, only valid at The Vision Parlor by phone-order, email, or in-person at our Auburn, CA location and during mobile appointments. Online orders will not be accepted at this time if you choose to use this benefit.
For all patients local within 5 miles of our Auburn, CA office, we offer mobile optician appointments at no cost. For appointments outside of the 5 mile radius, unless we are already in your area at the time of your appointment, there may be a travel fee associated.
Mobile Hours: (Outside of Office Hours)
Sun 7:30am-10:30am, 6:00pm-8:00pm
Mon 7:30am-10:30am, 6:30pm-8:30pm
Tue 7:30am-10:30am, 6:30pm-8:30pm
Fri 7:30am-10:30am, 6:30pm-8:30pm
Sat 7:30am-10:30am, 6:30pm-8:30pm
- Call and Schedule an eye exam at any Optometrist/Ophthalmologist.
- See your Optometrist for a Comprehensive Eye Examination which includes a refraction and overall eye health check. Retinal Screenings, OCT, Visual Field Screenings, etc. may be additional.
- Request for an official prescription from your Optometrist so you may fill the prescription with us.
- Ask to have your pupillary distance (PD) to be written down (for online orders not using the benefits below). In-person orders will be measured in-office with our Licensed Optician.
- Bring your prescription to us in-person and we will provide a proper eyeglass fitting and order your prescription eyeglasses for you. You can schedule an appointment to come in-office or use our mobile optician services if you prefer to have a Licensed Optician come to you. We encourage you to utilize this service since it’s now available to you!
- We will contact you when your glasses are ready. If ordering in-person, we will call/email you and you can schedule an appointment to have your glasses fitted. To have eyeglasses shipped to you, turn around time will typically take 3-4 weeks (taking into consideration delivery times to have the glasses shipped to you).