Medicare and Medi-Cal
coverage: Prosthetic eyes and related services are a covered procedure under Medicare and Medi-Cal
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 has strict guidelines
regarding the fitting and replacement of ocular prostheses.
Medicare pays 80% of their allowed amount
based on what part of the country you live. If you have a Medicare
supplement, it pays the
additional 20%. This office requires Medicare patients to cover their
professional service at the time they are provided. 50% of our fee is due upon
the first visit, and payment in full at the time the ocular prosthetic is
delivered. We do not accept assignment for Medicare patients ( except for
Medicare HMO's), however we will do all the billing for you and your insurance
reimbursement will be sent directly to you.
Medicaid claims are accepted with
a physician’s written order and the patient will have no co-pay or deductible unless they are on
a "share of cost" plan. It should be noted that not all ocularist accept
Medi-cal or Medicaid patients, so check with your ocularist.
- Blue Shield - PPO's: Most insurance will pay at least a portion of the fitting and supply fees for your artificial
eye. Prosthetic devices are categorized by insurance companies as Durable Medical Equipment, or
DME. As such, most insurers will pay 80 percent of their company’s allowed amount. This allowed
amount varies from company to company. Unfortunately, most companies will not divulge what their
allowed amounts for the service will be.
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.
Most ocularist offices will help you to secure the highest level of coverage for each
case, but don't assume the complete cost will be covered by your insurance.
Coverage issues can
usually be obtained by calling the Member Services telephone number listed
on your insurance card.
Health Maintenance Organizations (HMO): Kolberg
Ocular Prosthetics is contracted with most HMO’s in the San Diego County region.  Our
participation with these organizations outlines fees for service that allows for the patient to
have no co-pay or deductible in almost all cases. 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 hand before work begins. The
ocularist in your area should be able to help you gain the information necessary
to obtain coverage if it is provided by your HMO plan.
However, remember that it is your insurance and your responsibility to do the
legwork to get the HMO'S referral to your ocularist.