BILLING AND INSURANCE Q&A

1. What’s the difference between a “routine eye exam” and a “medical eye exam”?
•  A routine exam or “vision exam” checks for vision correction (refractive error), screens for eye diseases and updates glasses or contacts. If there is a possible or pre-existing problem you will need to return for a medical exam to evaluate for this.
•  A medical exam evaluates or monitors an eye condition (e.g., glaucoma, dry eye, diabetic retinopathy, etc.)

Insurance coverage depends on the reason for the visit. Medical insurance will typically pay for an exam if there is a medical diagnosis associated with the examination. Vision insurance is separate from medical insurance and does not pay for medical visits. This can be confusing. Please ask one of our staff members if you have questions

2.  What does the patient owe if they have both medical and vision insurance?
The primary coverage depends on the reason for the visit. Sometimes both plans are used, one covers the medical exam, the other covers refraction or materials.

3. How does insurance handle co-management between optometrists and ophthalmologists?
Co-management is when the care of a patient is shared between their optometrist and ophthalmologist. This is most common when a patient is referred to Dr. Zelenak for cataract surgery by an outside optometrist. Dr. Zelenak will evaluate the patient and perform cataract surgery if indicated. Once the patient’s eyes are stable following surgery they are referred back to their optometrist for continued care. Co-management is allowed if there is a transfer of care and clear documentation of each provider’s involvement in the surgery and follow up care.

4. Are cataract evaluations and surgery covered by insurance?
Yes, if the cataract significantly impairs vision and new glasses will not correct the problem. Problems with activities of daily living such as reading, driving, night vision, seeing the television, and problems with glare need to be documented to support medical necessity for the surgery. Medicare covers basic cataract surgery with standard lens implants. Patients pay out-of-pocket for Advanced Technology IOLs (toric, multifocal).

5. Are refractions (the test that determines your eyeglass prescription) covered by insurance?
Refractions are oftentimes not covered by medical insurance. The refraction is not considered a part of the medical exam by many insurers. If it is not covered by insurance it is self-pay. Medicare and most insurances allow practices to charge patients directly if they sign an ABN (Advance Beneficiary Notice). If you have vision insurance a refraction is a part of your vision exam benefit. This can be very confusing. Our staff can help let you know what is covered by your insurance.

6. Do I need a referral from my primary doctor to see an eye specialist?
Only for Medicare Advantage (HMO) plans, not for traditional Medicare.

7. Does Medicare cover routine eye exams?
No, Medicare does not cover routine eye exams or refractions for glasses.
It will cover exams for medical diagnoses (e.g., glaucoma, cataract, diabetic eye disease). Medicare will cover one pair of glasses or contacts after cataract surgery. This is a one time benefit and is only available if the glasses are dispensed within one year of the date of the surgery.

8. What’s the process for prior authorizations and referrals?
Many commercial and Medicare Advantage plans require pre-authorization for procedures (e.g., cataract surgery, intravitreal injections); some require referrals from a primary care provider for specialist visits.

9. Will Medicare cover glaucoma screenings?
Yes, Medicare Part B covers an annual glaucoma screening for patients at high risk, including:
•  Diabetes
•  Family history of glaucoma
•  African Americans aged 50+
•  Hispanic Americans aged 65+

10. Will Medicare pay for my new glasses after cataract surgery?
Yes, one pair of glasses or contacts is covered after cataract surgery (with standard lenses).

11. Why did I receive a bill after my Medicare visit?
Medicare covers 80% of approved services, the patient is responsible for the remaining 20% unless a secondary or supplemental plan is in place. Some services, such as refraction or routine eye exams, are not covered by Medicare.

12. Does Medicaid cover eye exams and glasses?
•  Minors (patients under the age of 21): Michigan Medicaid covers routine vision care for minors, including eye exams, corrective lenses (frames + lenses) and related services.
•  Adult patients (age 21 and older): Routine eye exams, refractions, eyeglasses and contact lenses for routine correction of vision are not covered under Michigan’s Medicaid unless there’s a medical necessity. Services that are covered for adults include:
   - Eye exams, diagnostics or treatments for chronic, acute or sudden-onset ocular conditions (e.g. glaucoma, cataract, diabetic eye disease)
  - Medically necessary contact lenses (if glasses are not appropriate) under certain circumstances
   - Special diagnostic tests, therapeutic services and ophthalmologic procedures when deemed medically necessary