Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the cost-sharing for the eye exam with photos. We decided that the Plan does not have to waive the cost-sharing for the eyeglasses.

You asked the Plan to waive the cost-sharing for the vision services. You say that these items and services are necessary, and you have not been asked to pay so much for these vision services in the past. The Plan says that the cost sharing for these services was applied correctly. The Plan states that they have paid the full $200 allowance for the eyeglasses, and your medical services will not be covered until you meet your maximum out-of-pocket.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The contract with the Plan says that there is a $0 copayment for Medicare-covered vision services.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan offers a $200 allowance toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses every calendar year. You are responsible for costs that exceed this allowance.

We decided that the Plan has to waive the cost-sharing for the eye exam.

The Plan argues that you are responsible for the costs of the eye exam because you have not met your out-of-pocket maximum. The Plan states that until this maximum is met, they will not cover their share of the cost for your medical care. Please note that this scenario describes a deductible. Generally, a Plan will not cover their share of your medical costs until your deductible is met. Once your deductible is met, a Plan will pay their share of the costs as outlined in the contract until you hit your out-of-pocket maximum. At this point, the Plan will cover everything in full and you will no longer be expected to pay your cost-sharing responsibility as outlined in the contract. Your Plan does not have a deductible, so the cost-sharing as outlined in the contract applies in this case.

The Plan has charged you 20% coinsurance for the eye exam with photos. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a Medicare-covered vision service. The item or service you asked the Plan to waive the coinsurance for falls within the Medicare-covered vision services benefit category and was billed with a medical exam procedure code and medical diagnosis. Therefore, we decided that the Plan has to waive the cost-sharing for the eye exam with photos (92250) provided on December 22, 2020.

We also decided that the Plan does not have to waive the cost-sharing for the eyeglasses.

We looked at the file and the Plan's rules. The Plan has covered their $200 allowance for the glasses as agreed upon in the contract. You have been asked to pay only the amount that exceeds the $200 annual allowance. Based on this information, we decided that the Plan does not have to waive the cost-sharing for the eyeglasses (V2020, V2303, V2750) provided on December 22, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.