Let’s Talk About Medicare Advantage Plans! 

Posted in Eye Blog, Mount Vernon, Sedro-Woolley, Stanwood, Whidbey

Medicare Advantage plans were created back in 1997 as part of federal legislation for the Balanced Budget Act of 1997. Enrollment in these plans has grown steadily and has 33.8 million subscribers, about twice the population as the city of New York, as of 2024. 

Medicare Advantage Plans Vary by County

In 2025, across the US, Medicare subscribers could choose from 3,719 plans. The plans offered vary by county, which means patients who live in our Skagit County service area have different plans to choose from than those who live in Island County. Each health insurance company often offers multiple plans, which vary based on monthly premium, deductibles, copay levels and referral requirements. 

Most Medicare Advantage plans offer services that traditional Medicare does not. These services could include routine physical exams, hearing aids, dental care and… a routine eye exam!  

How is a Routine Eye Exam Different?

A routine eye exam is one that is performed in absence of any eye complaints from the patient or where no chronic eye disease is present. It is intended by insurance to be a screening for eye disease and to check a patient’s visual acuity to determine if a patient may need glasses. The diagnosis would be something like myopia (near sightedness).  This visit is not intended to monitor or treat medical conditions. It is also important to know WHO covers the routine eye exam benefit. In many cases, it is not your Medicare Advantage health insurance!  

Who Pays For My Benefit?

Two of the biggest payers in the Medicare Advantage market are United Healthcare (UHC) and Humana. Both of these plans offer a routine vision exam benefit. However, they don’t pay for it. Wait a minute? How can they offer the benefit but not pay for it? This is confusing! It is because both of these payers have outsourced this benefit to a vision plan, either Spectera or EyeMed*.  

They do tend to hide this information in the small print. A call placed to UHC’s vision phone number will be answered “thank you for calling your vision plan”. It will take some time for you to find out you are not talking to United Healthcare; you are talking to Spectera. 

This is important because your eyecare provider may contract with UHC or Humana (like we do) but not contract with Spectera or EyeMed (we do not). To receive a routine eye exam you would need to be seen by an eyecare provider who is contracted with those vision plans. Most Medicare patients have medical eye conditions (cataracts, glaucoma, dry eyes, etc.) and so our office can bill your health plan for a medical eye exam rather than a routine eye exam.  

* We have recently learned UHC may pay the vision exam benefit directly for some of the their PPO plans.

What Do I Pay For?

The part you may be responsible for, depending on your Medicare Advantage plan, is the refraction. A refraction is done as part of your medical eye exam to determine your best corrected vision (you will know this test best as the one where the technician asks which lens you see better with, 1 or 2). This test gives the doctor important information on your eyes’ health and whether or not your vision can be corrected with glasses. Some Medicare Advantage plans consider this test to be part of your “routine vision” benefit and will only pay this when you see a provider contracted with your vision plan. 

This was a lot of information! It is clear to us why this is a confusing area for our Medicare patients and an area in which we believe insurance companies could be much more transparent with consumers. Until that happens, we do our best to alert you when you schedule an appointment; however, it is important to understand so you can make a fully informed decision when you select your Medicare Advantage plan.

P.S. If you enjoy insurance stats, check out this source: Medicare Advantage 2025 Spotlight: A First Look at Plan Offerings | KFF