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:

• People who live in certain institutions (like a nursing home) or who require nursing care at home.

• People who are eligible for both Medicare and Medicaid.

• 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, Medicare Advantage plans may require that you 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, inquire about the quality assurance policies of your plan and provider, including whether there is 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.

Page 3 of 3: Medicaid and vision benefits

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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 published on Wednesday, February 27, 2019