Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to provide additional reimbursement for the eyeglasses. We decided that the Plan
does not have to provide additional reimbursement for the eye exam.
You asked the Plan to provide additional reimbursement for the vision services. You say that these services
were received from in-network providers, and you are due additional reimbursement. The Plan says that neither
provider in this case is part of the Plan's network. You are responsible for 40% coinsurance for routine eye
exams received from out-of-network providers. The Plan's allowed fee for the eye exam is $52, and the Plan
has reimbursed 60% of the allowed cost for this service ($52 x 60% = $31.20). The Plan has also paid their rate
for the eyeglasses which amounts to $132.98. The Plan says that this claim was processed correctly, and you
are responsible for the remaining cost for these services.
We decided that the Plan has to provide additional reimbursement for the eyeglasses.
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 pays up to $200 per year for supplemental eyewear from in-network or out-of-network
providers. There is a $0 copayment up to the $200 eyewear allowance for these services.
We looked at the file and the Plan's rules. Documentation shows that you paid $189.98 for the eyeglasses
purchased on the date in question. The Plan applied their allowed fees for these services and reimbursed you
$132.98 for the eyeglasses. Because this is a direct member reimbursement, this part of the cost cannot be
written off as it was already paid by the enrollee. Per the contract, the enrollee is entitled to use up to $200 per
year for routine eyewear from in-network or out-of-network providers. There is no indication that the Plan will
only make payment for these services based on their allowed rate or that the enrollee may be charged more by
out-of-network providers. An allowance amount implies a flat rate that the enrollee may be reimbursed based
upon what was actually paid unless otherwise stated. The total cost of the eyewear is less than the $200 annual
allowance. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have been
met. Therefore, we decided that the Plan has to provide additional reimbursement for the eyeglasses purchased
on July 11, 2021, up to the full amount you paid.
We also decided that the Plan does not have to provide additional reimbursement for the eye exam.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 40%
coinsurance for a routine eye exam received from an out-of-network provider.
The record shows that you paid $79 for the eye exam provided on July 3, 2021. The provider in question is not
part of the Plan's network, and therefore you are responsible for 40% coinsurance for this service. The Plan's
allowed cost for the routine eye exam was $52, and the Plan has reimbursed you 60% of the cost of the allowed
amount and left you responsible for 40% coinsurance on the allowed amount. ($52 x 60% = $31.20. $52 x 40%
= $20.80). Coinsurance is always applied to the Plan's allowed rate or fee for a service. The difference between
the Plan's allowed cost for the service and the amount the out-of-network provider billed ($79 - $52 = $27) is
not the Plan's responsibility in this case. If this service had been performed by an in-network provider, the Plan
would be able to tell the provider that they need to refund you the disallowed amount. However, because this
provider is out-of-network, this price difference must be sorted between you and the provider. This means that
you have been reimbursed the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to provide additional reimbursement for the eye exam provided on July 3, 2021.
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.