Medicare Open Enrollment and Your Eyes: 6 Things to Check Before December 7

Medicare’s annual enrollment period runs from October 15 through December 7. Whatever you choose during those weeks sets your coverage for all of next year, including the parts that decide what you pay for cataract surgery, injections for macular degeneration, glaucoma care and your annual eye exam.

Most people review the premium and the drug list, then stop. Here is what to check if your eyes are part of the picture.

1. Check whether your eye doctors are still in network

Medicare Advantage networks change every year, and a plan that covered your ophthalmologist this year may not next year. If you are mid-treatment, for example receiving injections for wet macular degeneration or being monitored for glaucoma, a network change can interrupt care or send you to a new doctor in January.

Look up each of your doctors by name in the plan’s directory, and call our office at (727) 202-2020 if you want to confirm what we accept. Our accepted plans are listed here.

2. Check whether the surgery center is in network, not just the surgeon

Cataract surgery generates two separate bills: one from the surgeon and one from the facility. They are contracted separately, so it is possible for your surgeon to be in network while the surgery center is not. Ask about both.

3. Know the difference between vision coverage and medical coverage

This trips up almost everyone. Routine vision benefits cover refractions, glasses and contact lens fittings. Medical coverage handles disease: cataracts, glaucoma, diabetic eye exams, retina care. A plan with a generous glasses allowance can still have high specialist copays for the care that actually matters if something goes wrong.

4. If you are planning cataract surgery, do the math on both plan years

If surgery is likely next year, look at the specialist copay, the outpatient surgery copay and the out-of-pocket maximum, not the premium alone. A plan that costs a few dollars more per month can be cheaper in a year when you have two procedures. And if both eyes need surgery, each is billed separately.

5. Watch the prior authorization rules

Some Medicare Advantage plans require prior authorization for cataract surgery or for retina injections. That is not a reason to avoid a plan, but it does affect timing, and it is worth knowing before you schedule rather than after.

6. Do not assume Original Medicare covers everything

Original Medicare covers medically necessary cataract surgery with a standard lens implant, subject to your deductible and coinsurance, and one pair of glasses afterward. It does not cover premium lens upgrades chosen for refractive reasons, and it does not cover routine glasses or LASIK. A supplement plan changes your share of the covered portion, not the definition of what is covered.

Your enrollment checklist

• October 15: plans go live for comparison, and your current plan’s annual notice of change should already have arrived
• Check each of your doctors and your surgery center in the plan directory by name
• Compare specialist copays, outpatient surgery copays and the out-of-pocket maximum
• Separate routine vision benefits from medical eye coverage in your comparison
• Note any prior authorization requirements for eye procedures
• December 7: the window closes for changes that take effect January 1

How we make this easier at St. Michael’s

We verify your benefits before you schedule, and you hear the number from us rather than from a bill six weeks later. A few things about our practice simplify the coverage question:

• Your surgeon and our AAAHC-accredited surgery center are the same organization at the same address, so there is no surprise second network to check.
• The doctor you consult with is the doctor who operates and the doctor who sees you at follow-up.
• We are independent and family-owned, not part of a national chain, so decisions about your care are made in this building.
• Cataract surgery, LASIK, glaucoma, retina, cornea and routine exams all happen under one roof, so a change in your plan rarely means starting over with new doctors.

Frequently asked questions

Does Medicare cover an annual eye exam?

Original Medicare does not cover routine exams for glasses, but it does cover medical eye visits and annual dilated exams for patients with diabetes. Many Medicare Advantage plans add a routine vision benefit.

Can I change plans after December 7?

There is a Medicare Advantage open enrollment period from January 1 to March 31 that allows some changes, and special enrollment periods exist for specific circumstances. The main window is October 15 through December 7.

Will my plan cover a premium lens implant?

Premium lens upgrades are generally an out-of-pocket cost regardless of plan. Our guide to choosing a lens implant explains the options.

Questions about your coverage?

Our team checks benefits before you schedule, so you know what your plan covers and what you would pay. Book an appointment online or call (727) 202-2020.