Will Switching To Medicare Advantage Pay For New Glasses? Probably Not

October is Open Enrollment month. Medicare beneficiaries get a chance to make changes to their coverage. Here’s a question I received recently.

“I have a retiree plan that is adequate for my medical and dental needs, but it does not cover vision care and I really need new progressive bifocals. I am considering enrolling in a Medicare Advantage plan for those benefits and continuing with the retiree plan for medical care.”

Before making the switch, there are two things this man needs to know. It’s likely that the Advantage plan would become the primary payer, his coverage for anything Medicare covers. He would have to live with the benefits, costs, and rules. And, it’s also very possible that he may lose the retiree coverage and not be able to get it back if he enrolls in a Medicare Advantage plan.

Then, if he still wants to consider this idea, he can focus on vision coverage. Is it worth it to switch to Medicare Advantage?

Medicare coverage of vision services

Medicare’s coverage criteria establish the basics. Medicare covers these vision services:

• cataract surgery using traditional surgical techniques or lasers
• glaucoma tests for those at high risk
• • eye exams for those with diabetic retinopathy, and
• certain diagnostic tests and treatment for age-related macular degeneration.

Medicare also provides a nominal allowance for glasses or contact lenses after cataract surgery. (Just to give you an idea of what nominal means, my ophthalmologist’s discount post-cataract was more than Medicare’s allowance.)

Medicare does not cover routine vision services, including eye exams, refractions, eyeglasses and contact lenses.

What to know about Medicare Advantage vision care

• Just about every Medicare Advantage plan (99%) offers vision benefits.
• The usual Medicare Advantage rules can apply. You may need to receive services from a network provider and your physician may need to get prior authorization.
• Plans can limit the services. For example, a plan may cover only one routine eye exam a year and a new pair of glasses every other year.
• And just as with dental coverage, plans likely have a dollar limit for services. I did a quick check of vision coverage for plans sponsored by the seven largest Medicare Advantage insurers. The annual limits ranged from $100 every two years to $300 a year. Kaiser Family Foundation reported that the average limit was $160 for vision care. If you want to shop online and need only single-vision eyeglasses, you might be able to find a pair for that. But, if like the man asking the question, you opt for progressive bifocals or prefer to visit an optometrist, the $160 will get you half a pair, if you’re lucky.

Bottom line

During Open Enrollment, dig into the plan’s Evidence of Coverage and Summary of Benefits to determine exactly what vision benefits the plan provides and then check out the plan’s medical coverage and costs.

Switching to Medicare Advantage for vision coverage is not the smartest idea. You’ll get a routine vision exam and maybe a pair of glasses or contact lenses but then, you’ll have to live with the plan.