Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the office visit and eye exam with photos and reimburse
you $66.73 for the eyeglasses at issue. We also decided that the Plan does not have to reimburse you the full
$140, as you have requested.

You asked the Plan to reimburse you $140. You say that the price you were quoted by the provider does not
match what they billed the Plan. The Plan says that the members benefit for frames and glasses states that the
member is responsible for anything over the amount of $400.00. The provider submitted a claim to the Plan's
vision benefits vendor, and a payment was made to the member's provider in the amount of $160.00. We made
a call to the provider and they told us that they gave the member a onetime courtesy adjustment to their bill,
along with the adjustments from the Plan, making the members total due $498.92 for both the glasses and
medical eye exam. The provider submitted a copy of the ledger associated with the members' account showing
the member made two payments in the amount of $95.00, total payments from the Plan being $162.19, leaving
the member with their deductible amount due of $146.73 for vision services.

The Plan follows Medicare rules. The rules say that Medicare generally does not cover routine vision services.
However, the Plan has a supplemental vision care benefit beyond Medicare coverage. This means that the
Plan's coverage rules apply. The rules also say that for a service or item that is normally not covered, but could
be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage
is given, the enrollee is held harmless.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have been partially met. The office visit and eye exam with photos was provided by
a contract provider. The file does not show that the Plan provided notice that these services would not be
covered. Under Medicare rules, this means that the office visit and eye exam with photos is considered
approved by the Plan. In addition, the EOC shows that you have a $400 coverage limit for supplemental
eyewear benefits. The ledger from your provider shows that the total cost of the eyeglasses was $670. After
applying the Plan benefit of $400, this leaves a balance of $270, for which you are responsible. The record
shows that you made payments in the total amount of $190 for the eyeglasses at issue. This means that your
remaining balance with the provider should only be $80 in total. The record shows that your remaining balance
is $146.73. This means that the Plan must reimburse you the difference of $146.73-$80, which is $66.73 (or
adjust the remaining balance with the provider's office from $146.73 to $80). It is worth noting that the EOC
does not list a deductible for your medical benefits nor for your supplemental routine vision care benefits, as
stated by the Plan.

Therefore, we decided that the Plan must hold you harmless for the office visit and eye exam with photos and
adjust your remaining balance from $146.73 to $80 for the eyeglasses (or issue reimbursement to you in the
amount of $66.73). We also decided that the Plan does not have to reimburse you the full amount of $140 that
you asked for.

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.