In order to take advantage of laser-assisted in situ keratomileusis (LASIK), you will need to meet with a doctor, undergo an examination, and then move through surgery. That makes LASIK a medical procedure, and you may believe you can use your Medicare benefits to pay for care. The reality is complicated.
Medicare rarely pays for the full examination you need before LASIK. (Learn more) Your original Medicare plan will not pay for LASIK unless it is deemed medically necessary, and that is rare. (Learn more) Adding to your original Medicare coverage through another insurance company might help, but the rules between plans can vary dramatically. (Learn more)
Will Medicare Pay for Eye Exams?
Medicare is meant to help you cover the cost of unexpected medical care. In a way, this is a form of catastrophic health insurance. Your coverage does not help you to stay healthy or prevent disease as much as deal with a medical crisis when it happens. This coverage can be of great help, but it also offers a limited form of protection.
Consider eye exams. A regular eye exam can help you uncover hidden eye health conditions that could impact your ability to see clearly. The conversation you have with a doctor during an exam can also help you understand what to do to protect eye health. Yearly exams are vital, but according to Medicare.gov, your Medicare Part B plan only covers a yearly exam for the condition diabetic retinopathy, and that coverage is only offered to people who have diabetes.
The Medicare Learning Network clarifies the issue by explaining that eye examinations your doctor might use to prescribe eyeglasses for you are not covered by Medicare. Since a test of your vision is often included in a yearly exam, it's reasonable that Medicare would move to halt coverage for any kind of yearly exam. Since this is considered routine care, it would not be covered.
Doctors need to perform a thorough examination before clearing patients for LASIK surgery. During the exam, they measure the following:
- Tear production
- Visual acuity
- Cornea thickness
- Pupil size
- Eye pressure
- Eye symmetry
The purpose of this exam is to determine whether you are able to have LASIK surgery to correct your vision while leaving your eye healthy at the end of surgery. Since the goal of this examination is to determine your suitability for surgery, it would not be considered a covered benefit by Medicare.
Will Original Medicare Pay for Surgery?
Most insurance programs, including Medicare, use the term "medical necessity" to determine coverage. If a medical procedure is required in order to preserve health, it is typically considered a medical necessity and therefore approved for payment.
As an article in Public Administration Review points out, there is no universal list of what might be considered medically necessary. The U.S. Secretary of Health and Human Services determines the process by which that determination is made, and what is deemed necessary and what is not can change with time.
For example, in research published in the Journal of Refractive Surgery, researchers discuss the use of LASIK to help someone who encountered an amputation of a flap created during LASIK. This is a traumatic injury, and it required surgery to preserve the person's eye. In this case, LASIK was the best way to help that person recover.
In a case like this, LASIK is not used to amend vision to help the person eliminate contacts or glasses. It is a surgery to help preserve someone's eye health and vision. This is the sort of case that could be considered a medical necessity, and it could, in theory, be covered by Medicare.
In a second example, published in the journal Clinical and Experimental Optometry, researchers examined a patient who developed growth beneath her flap created during LASIK surgery. That growth prevented clear vision, and this is an issue that is sometimes amended with surgery. If this woman's issue was best amended with a second LASIK surgery, and no other type of surgery would help, she might be able to make a case to Medicare that it should be covered.
These are just two examples that highlight the complexity of using Medicare plans to help pay for LASIK. Routine surgeries to preserve vision rarely fall under these protections, meaning that people who want to use LASIK benefits to eliminate glasses may not be able to use their Medicare benefits to do so.
Will Additional Medicare Plans Pay for Surgery?
In addition to enrolling in a standard Medicare plan, you can enroll in a Medicare Advantage Plan (sometimes called Medicare Part C). According to the U.S. Department of Health and Human Services, these plans are subject to open enrollment periods, so you cannot join them at any time. You may need to wait for the next period to join.
Enhanced Medicare plans are offered through private insurance companies, although those plans are approved by Medicare. They must cover the same issues covered by Medicare, but some offer a few perks that Medicare does not offer. At times, these perks include LASIK for some people.
For example, Blue Cross Blue Shield of North Carolina in a Medicare Part C plan will cover LASIK for a specific set of patients. Those patients:
- Have been through cataract surgery or corneal transplant.
- Have a difference of more than 3 diopters between their eyes.
- Struggle to see clearly in a way that is not correctable with glasses or contacts.
All three of these conditions must apply in order for the surgery to be covered, so this is likely to be a benefit used by a small number of people. But it is available through the plan.
United Healthcare offers another additional Medicare plan, and here, LASIK is approved for astigmatism caused as a side effect of a prior surgery. This is the only way in which LASIK is approved in this plan, but again, it offers a way for some people to get LASIK surgery through their health care benefits.
How You Can Parse Your Benefits
Medicare rules are complicated, especially when you are considering an expensive surgery like LASIK. It is nearly impossible to perform a quick internet search and determine whether or not Medicare will pay for your care. The treatment you need depends on your health, your medical history, your plan, and so much more.
When you purchase insurance, you are given information about what is and what is not included. You can look through that information and determine whether or not LASIK seems to apply in your specific situation. If you are working with a private insurance company, you can ask your doctor to submit a preauthorization form to your insurance company, detailing why LASIK is right for you. Your doctor can attach your medical records to that request to give authorities the data they need to make a smart decision. You should hear back about whether or not you will be responsible for the cost.
You can also contact Medicare to find out about financial responsibilities, especially if you are using Medicare combined with private insurance. The U.S. Department of Health and Human Services reports that people can call the Medicare Benefits Coordination and Recovery Center, ask about a particular cost, and see if it is covered.
Some surgeons also have financial aid advisors that can help you understand your benefits, submit appropriate paperwork, and more to see if insurance will cover the cost of care. Some will charge a fee for that work while others do not. If you cannot make sense of insurance on your own, this can be an excellent way to get the answers you need.
If you are looking for a trusted LASIK provider to help you see clearly, contact us. We connect with providers all across the country, and we're happy to help you make a smart decision. Contact us to find out more.
Your Medicare Coverage: Yearly Eye Exam. Medicare.gov.
Items and Services Not Covered Under Medicare. (August 2018). Medicare Learning Network.
Defining Medical Necessity Under the Patient Protection and Affordable Care Act. (May 2013). Public Administration Review.
Epi-LASIK After Amputation of a LASIK Flap. (June 2006). Journal of Refractive Surgery.
Healthcare and a Holiday: The Risks of LASIK Tourism. (November 2013). Clinical and Experimental Optometry.
Understanding Medicare Advantage Plans. (September 2019). U.S. Department of Health and Human Services.
Medicare C/D Medical Coverage Policy. (December 2016). Blue Cross Blue Shield of North Carolina.
Coverage Summary: Laser Procedures. (February 2009). United Healthcare.
Medicare and Other Health Benefits: Your Guide to Who Pays First. (September 2017). U.S. Department of Health and Human Services.