Insurance is an important part of our profession, since it gives patients the ability to afford our services. Medicare is particularly important, but can be confusing. I’ve laid out answers to some of the basic questions about Medicare that incoming optometry students should know about.
1. Who is eligible?
Medicare is for those individuals who:
– Are 65 years of age or older and they or their spouse have paid at least 10 years of Medicare taxes.
– Have been receiving Social Security Disability Benefits for at least two years or,
– Have ERSD (End Stage Renal Disease) and/or are in need of a kidney transplant.
Although these reasons are the most common reasons to recieve Medicare, others may be eligible for Medicare for other reasons.
2. What are the types of Medicare?
Part A – This portion covers inpatient hospital stays, nursing home care, and hospice care. This part is usually offered to eligible participants at no cost.
Part B – This portion covers outpatient services such as doctor visits, radiology and laboratory services, and selected medical devices. Participants usually pay a premium for this part based on their income.
Part C (also known as Medicare Advantage) – In some cases, Medicare recipients chose to receive their benefits through a private insurance company such Aetna, Blue Cross, Humana, etc. These private insurance policies are partially funded by the federal government and may include such things as co-pays and deductibles, which are the patient’s responsibility. They may also cover other services not covered by traditional Medicare (such as a routine eye exam).
Part D – This portion covers medically necessary prescription drugs. Participants also pay a premium based on their income.
3. Does it cover optometrists and eye related services?
Yes! Since 1987 optometrists have been considered physicians by Medicare and can be reimbursed by Medicare for any covered services rendered. However not all eye services are covered by Medicare. Routine vision exams, eyeglasses, and contact lenses (except after cataract surgery) are not covered by traditional Medicare. Vision exams are covered if there is a medical complaint. Exams and related diagnostic tests and treatment are also covered if a patient has certain ocular conditions such diabetic retinopathy, glaucoma, or macular degeneration.
4. How are services reimbursed?
The Center for Medicare and Medicaid Services (CMS) assigns a dollar amount for each service, test, or in some cases drug, that is covered. This dollar amount is calculated based on the expense to the practice, the work performed by the doctor, the cost of the liability insurance, and the geographic location where the service was rendered. Usually Medicare will pay the optometrist 80% of that cost while the patient will be responsible for the remaining 20%. Medicare Advantage plans may reimburse an optometrist differently.
5. Why is Medicare important?
In 2012 there were almost 50 million people who were Medicare recipients, a significant portion of the US population. Many people within this population need eye care and Medicare pays for a portion of these expenses. In turn, this becomes an important part of an optometrist’s income, especially if they see geriatric or disabled patients. In addition, there are strict regulations governing the diagnostic codes that doctors can use for Medicare reimbursement.
For more information about Medicare, visit the official government website http://www.medicare.gov/
Kamen, Roger D. 2009. Medicare and Medicaid. Optometric Care within the Public Health Community. Old Post Publishing. Cadyville, NY 1-16.