Your Medicare and secondary insurance don’t pay for the following:
Refraction(where the doctor checks your prescription glasses, this will allow to test for the most recent prescription glasses) is not covered. Your out of pocket is $70.00
If you required the doctor to co-manage with another healthcare provider (correspondence), it is not covered. Your out of pocket is $60.00.
Read this notice, so you can make an informed decision about your care
Ask us any questions that you may have after you finish reading
Choose an option below about whether to receive the Refraction listed above
If needed, the additional Co-management fee listed above
PLEASE CHECK ONLY ONE BOXES BELOW. WE CANNOT CHOOSE AN OPTION FOR YOU.
**Our office is a non-participating provider for Medicaid and the QMB program. If you have this benefit, you will be responsible for the refraction fee and the 20% co-insurance that Medicare does not cover payable at the time of service.
This notice is a policy of our office, not an official Medicare decision. If you have other questions on this notice or Medicare billing, Call 1-800 633-4227 / TTY: 1-877-486-2048. CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: