New Year, New Plans - How to Navigate Medicare Advantage Plans in 2020

By Mary Hollis Stuck February 24, 2020

With the number of Medicare Advantage plans on the rise, the optometry industry is in a uniquely complicated position. Being an industry that provides both medical care and material goods, we have the unfortunate responsibility of having to properly file not one, but two insurances, in most cases. This may act as a guide to help simplify the options your patients have.

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According to data collected by KFF.org¹, the number of Medicare patients that now use an Advantage plan has doubled in the past decade. In 2019, approximately 34% of Medicare beneficiaries were on Advantage plans instead of traditional Medicare. While this may simplify things for them when they visit the primary care physician, it can complicate their visit to their optometrist or ophthalmologist. As of 2020, almost all of the Medicare Advantage plans also provide the beneficiary with a vision benefit plan. This means that your office must fight the “which insurance do we bill” battle with 34% of your Medicare patients.

The battle of the insurance has been around since the introduction of vision plans. If a patient comes in for what they consider to be a “routine eye exam,” but their chief complaint is “my eyes are constantly dry and burning,” or “I’m pretty sure my cataracts are worse, my vision has changed and glare is really bothering me,” they must be properly billed to their medical plan. Unfortunately for the patient, this does generally mean a relatively high specialist copay. Sometimes, the copay is up to $50, when their VSP plan may charge $0. It’s up to the staff at your office to ensure the patient realizes their medical insurance may be billed instead of their vision plan, depending on the conversation had in the exam room. While it is helpful for doctors to be aware of charges, the discussion of cost and insurance is something that should be done between the staff and the patient. The patient’s financial situation should never sway the way the doctor performs the exam, or the way they code. Remember, the practice’s bottom line, or even the doctor’s license, is on the line for any improper coding.

To simplify these plans, I have broken down the top three.

-       Blue Cross Blue Shield - Specialist Copay - Refraction Not Covered - Utilizes VSP Network

-       Humana - Specialist Copay - Refraction Not Covered - Utilizes Eyemed Network

-       United Healthcare - Generally No Copay - Refraction Covered 1/Year - Utilizes Spectera Network

While it used to be common for optometrists to not accept these Advantage plans, that is highly unrecommended in 2020. However, just because you take the medical plan does not mean that you must also contract with the vision plan. Vision plans often dictate which labs to use, which materials are allowed, and require you to have frames that may be well under the retail value of your typical frame selection. To discourage patients from taking their business to other opticals after seeing the doctor at your practice, I might recommend offering a standard discount for eyeglasses if the patient chooses to order from you. While extending the patient a 20-30% discount for eyewear will affect your profit margin, you will still keep the business that you may not have been able to keep otherwise. Make it an office policy to extend any discounts, and also offer detailed receipts for the patient to submit for possible reimbursement. If you are able, even offering to assist them in filling out their out of network claim forms would go the extra mile. Many patients would prefer to get all of their services and materials in the same place, so simplifying this process would make that more likely.

Billing and coding practices are constantly changing in the world of optometry. Because of the variety of care ODs provide, simplifying insurance remains a mythical idea, something everyone strives for but few are actually able to succeed in. By educating your staff, and making sure they properly educate your patients, it is possible to streamline this billing process slightly, decrease your time spent fielding billing questions, and allow you to maintain proper coding and documentation in the exam lane. By properly utilizing these plans, and fighting to keep material purchases in house, 2020 could prove to be a very productive year for your practice.



  1. Jacobson, Gretchen, Freed, Meredith, Damico, Anthony, and Neuman, Tricia. “A Dozen Facts about Medicare Advantage in 2019.” June 06, 2019. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2019/ Accessed 01/28/2020.

Mary Hollis Stuck

Mary Hollis has been in the optical field since 2005. She has filled many roles within optometric practices and is a billing guru. She is passionate about providing excellent customer service for patients, which she helps to achieve while finding ways to increase practice productivity. Currently, Mary Hollis manages the billing department at Eye Associates of Cayce, a multi-doctor private practice in Cayce, South Carolina.

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