Artificial eyes are considered are considered medically necessary and are classified under Durable Medical Equipment (DME). Most insurance plans do cover at least a portion of the costs, but they also have guidelines regarding replacements and benefits vary.
Typically, for any single item of DME, there are multiple sources of payment. For example, Medicare will contribute. Medicare supplemental insurance may also pay a portion, and the individual may pay a part out-of-pocket as well. To minimize out-of-pocket costs, it is helpful to be aware of all the possible sources of funds that may be available.
Ocular prosthetics are not covered under vision benefits. Contact your insurance company for more information on your plan benefits.
Medicare and Medicaid coverage: Prosthetic eyes and related services are a covered procedure under all Medicare and Medicaid guidelines. Prior to beginning your fitting, a request from your ophthalmologist is required. This request can be in the form of a written prescription from your ophthalmologist or a letter requesting this service. Medicare Part A (hospital coverage) may contribute, but has more restrictive eligibility criteria. Medicare Part B (medical coverage) is much more likely to help. In either case, there will be copayment requirements.
Medicaid will pay for home medical equipment, often covering 100% of the cost. However, Medicaid is only for individuals with very low incomes and extremely limited assets. There are many different Medicaid programs and Medicaid Waiver programs. And each one has different rules and benefits with regards to durable medical equipment.
Preferred Provider Organizations (PPO’s)
Preferred Provider Organization (PPO): If you have a PPO plan, you can expect your insurance to cover at least a portion of the artificial eye cost. Most insurers will pay 80 percent of their company’s allowed amount. This allowed amount varies from company to company, but it can be found by reviewing the plan’s policy or by calling the Member Services telephone number listed on your insurance card. Generally, the allowed amounts assigned by private insurers are well below the office fee for service. The patient will be responsible for any annual deductible as determined by their policy and the 20% co-pay amount. Additionally, the patient will be responsible for the difference between the allowed amount of their policy and the billed charges.
Health Maintenance Organizations (HMO’s)
Health Maintenance Organization (HMO): HMO’s are unique in the respect that prior authorization must be obtained from your medical group prior to seeing the ocularist for service, and the authorization needs to be in-hand before work begins. If you have questions regarding obtaining the prior authorization documentation for your artificial eye, please contact the office nearest to you for assistance. However, remember that it is your insurance and your responsibility to do the legwork to get the HMO’S referral to your ocularist.
Veterans Health Care and VA Insurance
The Department of Veterans’ Affairs, either through insurance, grants, or other assistance programs, helps elderly veterans with the cost of medical equipment. Assistance may come in the form of paying Medicare’s co-payments, cash, or actual equipment and supplies. Assistance may come from a variety of sources within the VA such as: TRICARE for Life, CHAMPVA for Life, VD-HCBS, or HISA and other grants.