Insuring Your Eye Health in Ohio

Prevent Blindness Ohio

1500 W Third Ave, Ste 200

Columbus, Ohio 43212

614.464.2020

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Most people require some kind of eye care throughout their lifetime,

but how do they pay for it? Insurance can be a confusing topic in any

circumstance but this is especially true when it comes to our eye health.

Insurance for eye health care can come from various sources. It may be

employer-sponsored medical or vision insurance, individually purchased

medical or vision insurance, Medicare, Medicaid, state children’s health

insurance programs, or other public or private programs. This general

overview of some key topics related to your vision insurance will help

you navigate an increasingly complex arena and allow you to better care

for your vision and eye health.

There are many distinctions between insurance plans, so check your

plan documents carefully to determine what is covered, how often, and

what your associated out-of-pocket costs may be.

Medical Insurance vs. Vision Insurance

Vision insurance and medical insurance cover different services, but the

distinction can be confusing.

Medical insurance (also commonly called “health insurance”)

offers coverage for most services related to the health of the eye

itself when provided by an eye care professional – an optometrist

or ophthalmologist. For example, exams and tests associated with

diagnosed cataracts, glaucoma, diabetic eye disease, and other

conditions that require speciﬁc counseling, documentation, follow-

up care, regular monitoring and/or referral to a surgeon, would be

covered by your medical insurance. While many plans do not cover

routine exams to determine if there is an eye problem in the general

population, some may include regular dilated eye exams to check

for signs of disease in individuals at high risk. However, there is a

growing trend among medical insurance plans to cover a routine eye

exam, so be sure to check with your insurance carrier about your

plan’s beneﬁts.

Medical insurance does not cover routine eye care related to

refractive error to determine your eyeglass or contact lens

prescription. It also does not generally cover the costs of eyeglasses

or contact lenses.

Vision insurance is often sold as a supplemental insurance product

to cover the cost of routine eye care. This generally includes a

comprehensive eye exam, any associated refraction fee to determine

your eyeglass prescription, and some allowance for glasses or

contact lenses. A contact lens exam may be covered.

Insuring Your Eye Health in Ohio

Insuring Your Eye Health in Ohio—Continued

Which Insurance Will Cover My Eye Care?

Both vision and medical insurance can be used in your optometrist or

ophthalmologist’s ofﬁce, but which insurance plan pays for your eye care

generally depends on the reason for your visit. If your diagnosis for the

visit relates to refractive error, such as astigmatism, nearsightedness,

or farsightedness, it will be covered by your vision insurance. If the

diagnosis for the visit relates to glaucoma, cataract, conjunctivitis, or

other conditions that require medical care, it will be paid for by your

medical insurance. “Medical care” in this case can be offered by any

provider licensed to provide that care in Ohio; this usually includes both

optometrists and ophthalmologists.

What If I Don’t Have Health Insurance?

There are many options for health insurance for your family. If you are

unemployed, or if your employer does not offer health insurance, you

may be eligible for subsidies to help you pay for insurance offered

through the health insurance marketplace. Based on your household

income, your child may be eligible for Medicaid. Go to beneﬁts.ohio.gov

to learn if you qualify for Medicaid or call 800.324.8680. Individuals up to

138% of the federal poverty level (annual income of about $16,000/year)

may be eligible for Medicaid.

If you don’t qualify for Medicaid and need health insurance, visit the

Health Insurance Marketplace at Healthcare.gov. Depending on your

income, you may qualify for subsidies. Insurance offered through

Marketplace is not required to include vision care for individuals aged

21+, however some plans may offer it as part of the plan and/or as a

supplemental plan.

Vision Services for Children: The Affordable Care Act

and Your Child’s Eyes

Recent changes in federal law may impact the kinds of vision and eye

health services your child has access to through health insurance.

Starting January 1, 2014, all individual health insurance plans, small

group insurance plans, or plans sold in the new state-based health

insurance marketplaces (exchanges) will have to include a set of

“essential health beneﬁts” (large group plans are currently excluded

from this requirement). Included in this list of “essential” services is

coverage for children’s vision.

In Ohio, this means that new insurance plans will cover one

comprehensive eye exam and one pair of glasses each year for

children up to age 21. Co-pays and deductibles may apply. Children,

ages 0-20, living in families with annual income up to 200% of the

federal poverty level (annual income of about $47,000/year for a

Insuring Your Eye Health in Ohio—Continued

family of four) may be eligible for Medicaid. A comprehensive eye exam, eyeglasses and other vision

services are provided annually at no cost to the recipient.

Also starting January 1, 2014, insurance plans must cover certain preventive services without a copay

or coinsurance; this includes vision screening for kids. This screening would likely be offered in your

pediatrician’s ofﬁce as part of a well-child visit.

To ﬁnd out more, visit HealthCare.gov or call 800.318.2596.

Vision Services for Older Adults – Medicare and Your Eyes

Medicare beneﬁciaries, especially those at risk for or diagnosed with a variety of diseases, are entitled to a

number of vision-related services. It is especially important for people with diabetes, a family history of

glaucoma, or those who have suffered an eye disease or injury to be aware of and utilize these beneﬁts.

Below are details about medical beneﬁts that may be available to you.

“Welcome to Medicare” Preventive Visit

The “Welcome to Medicare” visit is an excellent way for you to get up-to-date on important screenings and

vaccinations, as well as to talk with your health care provider about how to stay healthy. You can get this

introductory visit only within the ﬁrst 12 months you have Medicare Part B (medical). This visit is covered one

time. Your doctor will:

• Record and evaluate your medical and family history, current health conditions, and prescriptions.

• Check your blood pressure, vision, weight, and height to get a baseline for your care. Keep in mind

the vision check is a screening for vision loss risk factors, not an eye exam through dilated pupil.

• Make sure you’re up-to-date with preventive screenings and services, such as cancer screenings

and shots.

• Order further tests, depending on your general health and medical history.

Following the visit, your doctor will give you a plan or checklist with screenings and preventive services that

you need. Ask about eye exams!

Routine Eye Exams

Medicare does not generally cover the costs of routine eye exams, with some exceptions. Medicare does

help cover the exam if you have diabetes, or are at risk for glaucoma. Keep in mind that Medicare does not

cover refractions for eyeglasses or contacts even as a part of some otherwise covered exams. Check with

your eye care professional for more information. Medicare does not cover eyeglasses or contact lenses,

except immediately following cataract surgery. Medicare does cover an eye exam for medical reasons, such

as in the case of injury or disease. Medicare Advantage plans, which are administered by private companies,

often choose to offer vision coverage and traditional Medicare beneﬁciaries also have the option to purchase

supplemental coverage (Medigap) in addition to their Medicare coverage that may cover routine eye care or

help to cover the cost of deductibles and other fees.

Glaucoma

Glaucoma is called “the sneak thief of sight” because often there are no warning signs, but there is

treatment for glaucoma if detected early. A leading cause of blindness, glaucoma affects close to 2.7

Insuring Your Eye Health in Ohio—Continued

million Americans age 40 and older. Medicare provides annual coverage for glaucoma screenings if you are

considered to be at high risk for glaucoma. High risk is deﬁned as:

• Individuals with a family history of glaucoma – family deﬁned as a blood parent or sibling;

• Individuals with diabetes - either diet-controlled, oral-agent controlled, or insulin-dependent;

• African Americans age 50; and

• Hispanic individuals age 65 or older.

The covered exam for glaucoma includes a visual acuity screening; a dilated eye examination; intraocular

pressure measurement; and direct ophthalmoscopy.

Medicare will cover 80 percent of the doctor’s exam fee. You or your secondary insurance must pick up the

deductible and the remaining 20 percent balance. A minimum of 366 days is required between glaucoma

screening visits.

Find out more about glaucoma: www.preventblindness.org/glaucoma-learning-center

Diabetes

If you have diabetes, you are at risk for developing diabetic retinopathy, glaucoma, and cataracts. Diabetic

eye disease can affect anyone with diabetes. Often there are no symptoms, so it is important to see your

eye care professional regularly for a comprehensive eye exam.

Medicare beneﬁciaries with diabetes qualify for the annual glaucoma screening beneﬁt. This beneﬁt includes

a comprehensive eye exam. Because people with diabetes need to have an eye exam at least once a year,

Medicare beneﬁciaries should be sure to make full use of the yearly glaucoma screening beneﬁt (discussed

above) to receive an eye exam that can check for both glaucoma and diabetic retinopathy.

Find out more about diabetes and your eyes: www.preventblindness.org/diabetes-and-your-eyes

Cataract Surgery

Cataract affects millions of Americans and is a leading cause of blindness worldwide. In the U.S., cataract

surgery is the most commonly performed surgical procedure in those 65 and older.

Medicare beneﬁciaries have two choices for cataract surgery in addition to the cataract removal: receiving

basic lens replacement (IOL), paid in full by Medicare up to $2,000, or applying the credit to new

replacement lenses that can correct both near and farsightedness (multifocal IOLs). Patients are then

responsible for paying the difference.

Medicare also covers corrective eyeglasses or contacts following cataract surgery with an implanted

intraocular lens. Medicare pays 80 percent of the Medicare-approved amount for one pair of eyeglasses or

contact lenses after each cataract surgery. The beneﬁciary pays any additional charges for upgraded frames

and the Part B deductible.

Find out more about cataract: www.preventblindness.org/cataract

Age-related Macular Degeneration (AMD)

AMD diminishes central vision that currently affects the vision of more than 2 million Americans age 50 and

older and is a leading cause of blindness. AMD is a progressive disease that, if left untreated, can result in

severe vision loss and even blindness.

Insuring Your Eye Health in Ohio—Continued

Medicare Part B covers treatment for beneﬁciaries with age-related

macular degeneration, including Avastin, Eylea, Lucentis, pegaptanib,

and ocular photodynamic therapy with verteporﬁn (Visudyne). The

beneﬁciary pays 20 percent of the Medicare-approved amount for

the drug and the doctor’s services or a co-payment if the treatment

is offered in a hospital outpatient setting.

Find out more about AMD: www.preventblindness.org/age-related-

macular-degeneration-amd

Prescription Drug Beneﬁts

All Medicare beneﬁciaries, no matter how they get their health care

today or whether they have existing drug coverage, are eligible for drug

coverage under a Medicare prescription drug plan (also known as a

Part D plan). This includes eye medications.

There are penalties for people who miss the below enrollment deadlines:

• October 15 – annual open enrollment period begins

• December 7 – annual open enrollment period ends

• January 10 – new choices take effect

Medicare prescription drug plans will vary depending on where you live,

and each plan is different. Contact the Centers for Medicare and Medicaid

Services (800.633.4227 or www.medicare.gov) to better understand

your choices.

Financial assistance is available for those who meet certain income

and resource limits. Contact the Social Security Administration

(800.772.1213 or www.socialsecurity.gov) to learn more.

Medicare Advantage

Medicare Advantage plans are Medicare plans administered by

private insurance companies. They are available to all Medicare

eligible individuals and must cover all the services covered by

traditional Medicare. However, these plans have the option to

structure themselves in unique ways and most offer additional

services, such as coverage for vision or dental care. Many of

these plans cover routine eye exams and offer a glasses or

contact lens beneﬁt.

Help with Medicare

The Ohio Senior Health Insurance Information Program (OSHIIP)

funded by Medicare provides objective information about Medicare

related issues. One-on-one counseling and assistance is available to

people with Medicare and their families.Contact them at 800.686.1578

or www.insurance.ohio.gov.

VISION COVERAGE WITH PUBLIC FUNDING IN OHIO–2014

MEDICAID

HEALTH EXCHANGE–

AFFORDABLE CARE ACT MEDICARE

NUMBER OF

PEOPLE AFFECTED

512,000 Ohio adults on Medicaid before

Medicaid Expansion began on 1.1.14

275,000 additional adults eligible on 1.1.14

Total adults expected to be covered by

Medicaid in 2014 = 787,000

1.15 million children on Medicaid prior

to 1.1.14

1.15 million children expected to be covered

by Medicaid in 2014

Total adults and children expected to be

covered by Medicaid in 2014=1.9 million

502,902 uninsured adults btw 139–400%

FPL may qualify for subsidies if they

purchase health insurance on the Exchange

(assuming they did not turn down affordable

and adequate coverage offered by their

employer).

1.622 million in Ohio

ELIGIBILITY FOR

CHILDREN

Uninsured up to 200% of poverty ($47,100 for

a family of 4)

Uninsured between 200–400% of federal

poverty level may qualify for a subsidy.

Some children qualifying for SSDI with

permanent/severe disabilities may be

eligible for Medicare

ELIGIBILITY FOR

ADULTS

Uninsured up to 138% of poverty ($15,856

for single individual) who are not 65 and

older, pregnant, eligible for Medicare

Part A, enrolled in Medicare Part B, SSI

beneﬁciaries, or unauthorized immigrants

Uninsured between 139%–400% of federal

poverty level may qualify for a subsidy.

Age 65+, citizen, eligible for SS, or under

age 65 with certain permanent/severe

disabilities

VISION COVERAGE

(AGES 0–20)

Vision screening as part of periodic well-

child primary care exams

Comprehensive vision examination–annual

Frame and lenses–annual

Vision screening as part of periodic well-

child primary care exams, no co-pay or

deductible applied

Comprehensive vision examination–annual,

co-pays and deductibles apply

Frame and lenses–annual, co-pays and

deductibles apply

Vision screening as part of periodic well-

child primary care exams

Comprehensive vision examination–annual

Frame and lenses–annual

VISION COVERAGE

(AGES 21–59)

Vision screening as part of well-patient exam

with primary care provider

Comprehensive vision examination–every

2 years

Frames and lenses–every 2 years

No requirements for vision care coverage 80% of eye exam if glaucoma risk

80% of eye exam if diabetic or at risk

$2000 toward cataract surgery

80% of cost of glasses after cataract surgery

80% of drugs for AMD treatment

Part D medication coverage

No glasses covered

VISION COVERAGE

(AGE 60+)

Vision screening as part of well-patient exam

with primary care provider

Comprehensive vision examination–annual

Frame and lenses–annual

No requirements for vision care coverage 80% of eye exam if glaucoma risk

80% of eye exam if diabetic or at risk

$2000 toward cataract surgery

80% of cost of glasses after cataract surgery

80% of drugs for AMD treatment

Part D medication coverage

No glasses covered

VISION COVERAGE

(AGE 65+)

Same as 60+ if dual-eligible with Medicare Not applicable

Welcome to Medicare Vision Screening

80% of eye exam if glaucoma risk

80% of eye exam if diabetic or at risk

$2000 toward cataract surgery

80% of cost of glasses after cataract surgery

80% of drugs for AMD treatment

Part D medication coverage

No glasses covered