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.
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:
1-800 MEDICARE or [email protected]
Please fill out the following form below, to let us know your option regarding "Refraction Testing". Thank you.
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