Health Column: What eye care does Medicare cover?

03/02/2011 10:12 AM |

Dear Marci,
I have cataracts, and I would like to set up an appointment with my eye doctor. When does Medicare cover eye care?
Miriam

Dear Miriam,
While Medicare will not generally pay for routine eye care, it will pay for some eye care services if you have a chronic eye condition, such as cataracts or glaucoma. In that case, Medicare will cover surgical procedures to help repair the function of the eye due to these conditions. Medicare will cover surgery to remove the cataract and replace your eye’s lens with a synthetic intraocular lens.
Eyeglasses or contacts are covered only if you have had cataract surgery during which an intraocular lens was placed into your eye. Medicare will cover a standard pair of untinted prescription eyeglasses or contacts if you need them after surgery. If it is medically necessary, Medicare may pay for customized eyeglasses or contact lenses.
An eye exam to diagnose potential eye disease is covered. If you are having vision problems that indicate a serious eye condition, Medicare will pay for an exam to see what is wrong, even if it turns out that you don’t have an eye disease.
Medicare will cover yearly eye exams only if you have diabetes or are at high risk for glaucoma.

Dear Marci,
I’m 64, self-employed and have health insurance as an individual. If I don’t take Medicare Part B when I turn 65, can I enroll without penalty during an eight-month Special Enrollment Period after I retire?
Miguel

Dear Miguel,
No. If you are self-employed and have health insurance as an individual and are not part of a group plan with at least one other member, your coverage does not qualify as a group health plan (GHP). Therefore, you would not qualify for a Special Enrollment Period (SEP), and you should enroll in Part B as soon as you become Medicare-eligible — in your case, when you turn 65. If you delay enrollment, you will have to wait for the General Enrollment Period in January to apply for Medicare, and your coverage will not begin until the following July. You will also have to pay a premium penalty for every 12 months you delay enrollment. If you are self-employed, approaching 65 and thinking of delaying Part B enrollment, you may want to consider joining either a group health plan that is part of a multi-employer plan or an association, such as the National Association for the Self-Employed, that offers group health plans to its members. If you are enrolled in such a plan, you are entitled to an SEP.

Dear Marci,
I would really benefit from a Medicare Savings Program, but I am slightly over the income limit for the programs in my state. Should I still apply?
Wendy

Dear Wendy,
Yes. If your income is above the income and asset guidelines, you should still apply. You may still qualify for a Medicare Savings Program because certain income and assets may not count.
Please remember that income and asset guidelines vary from state to state. In all states, the following income will never be counted: the first $20 of all income; the first $65 of monthly wages; one half of your monthly wages after the $65 is deducted; and food stamps.
Some states may not count more income, or may exclude things from your income, such as the money you use to pay health insurance premiums (like Part B premiums). Some states allow you to have a higher income if more than two people live in your household.
In all states, the following assets will never be counted: your primary house; your car; household goods and wedding and engagement rings; burial plots; burial funds for you and your spouse valued up to $1,500 each; and life insurance with a cash value of less than $1,500
Many states do not count other types of assets while some states have no asset test.
Call your local Medicaid office for exact rules on how to apply for a Medicare Savings Program in your state.

Marci’s Medicare Answers is a service of the Medicare Rights Center (medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare.

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