As the world’s second leading cause of blindness, glaucoma continues to take over people’s lives. Glaucoma is an eye condition in which the optic nerve becomes damaged leading to vision loss. The optic nerve is the nerve that transfers images formed by the retina to the brain. Most of the time, the optic nerve becomes damaged due to high eye pressure.
There are many forms of glaucoma, but the most common one is Primary Open-Angle Glaucoma (POAG). In fact, POAG affects nearly three million Americans.
POAG is simply when the drainage canal is clogged. When the drainage canal is clogged, pressure builds up in the eye. Therefore, damaging the optic nerve. See Figure A.
Unfortunately, people with open-angle glaucoma usually don’t have any warning signs that they are developing the condition. By the time people with this form of glaucoma notice their vision impairment, they have already had the disease for quite some time.
Another form of glaucoma that isn’t seen as often is Angle-Closure Glaucoma (ACG). In angle-closure glaucoma, the inner eye pressure increases at an astonishing rate compared to open-angle glaucoma.
Instead of the drainage canal becoming clogged, the path to the canal is merely blocked. This happens when the iris either falls towards the lens or pushes against the cornea. See Figure B. Symptoms of ACG include extremely blurred vision, headaches, nausea, and eye pain.
People over sixty years old are six times more likely to get glaucoma then people who are under sixty. Therefore, Medicare beneficiaries should know how their insurance covers glaucoma diagnosis and treatment.
Medical Treatments for Glaucoma
There are three main forms of treatment for glaucoma. These include oral medications, eye drops, and surgery.
Oral Medications and Eye Drops
Some types of medications used to treat glaucoma lower eye pressure. These include medications such as Travoprost, Pilocarpine, and Latanoprost.
Beta blockers are another type of medication that that slow down your heart rate and lower your blood pressure. When beta blockers are in the form of an eye drop, they can lower eye pressure. Some examples of beta blocker eye drops are Betaxolol, Timolol, and Carteolol.
The two main surgery procedures doctors perform for glaucoma patients are Laser Eye Surgery and Trabeculoplasty.
Laser eye surgery consists of using a laser to eliminate unwanted tissue to recover the original shape of the cornea. This ultimately is meant to improve eye sight. Trabeculoplasty is a procedure that also uses a laser, but it is meant to improve the drainage from the eye so to lower the eye pressure.
Like mentioned above, these are treatments for glaucoma, not cures. Like so many diseases, a cure has yet to be discovered for glaucoma.
Does Medicare Cover Glaucoma Diagnosis and Treatment?
In short, yes. Medicare covers procedures and treatments that are medically necessary along with preventative services.
Breakdown of What Original Medicare Covers
Original Medicare consists of two parts, Part A and Part B. Each part of Original Medicare covers certain portions of your medical needs. Medicare Part A covers your inpatient hospital stays among other things while Medicare Part B covers your outpatient services.
If you receive your surgery in an inpatient hospital setting, Medicare Part A would cover expenses related to your stay. If you are at a high risk of developing glaucoma, Medicare Part B will cover a glaucoma screening once a year.
You are considered to be high risk if you
- Have a family history of glaucoma
- Are African American and 50 years or older
- Are Hispanic and 65 years or older
In order for Medicare to cover your screening, your test must either be performed by or supervised by an eye doctor who is lawfully allowed to do the test in that state.
Does Medicare Cover the Necessary Drugs?
Whether or not your Medicare Part D plan covers your necessary drugs depends on the plan’s drug formulary. A drug formulary is a list of medications that a plan covers. Both stand-alone Part D drug (PDP) plans and Medicare Advantage Prescription Drug (MAPD) plans have formularies.
There are some drugs that every plan is required by Medicare to cover. However, each plan still get to set the copays for each tier of medication. Keep in mind that just because your plan covers the medication doesn’t mean that it will be an inexpensive price. It depends on the retail cost of the medications and which tier the plan slots the drug into.
You can see below a list of a few different medications used for glaucoma. Next to them is the estimated percentage of Medicare plans that cover the drug. See Figure C.
*Travoprost usually isn’t covered by Medicare
Costs of Treating Glaucoma
Depending on what stage of glaucoma you suffer from, your annual medical costs wil vary.. People with early stages of glaucoma typically spend about $600 a year for treatment. Individuals more severe cases spend about $2,500 a year for treatment.
Costs with Medicare Part A and Part B
Medicare requires you to pay your own deductibles and coinsurance. As of 2018, the Medicare Part A deductible is $1340. Once that has been paid, Medicare will cover your first 60 consecutive days in the hospital.
If you are in the hospital longer than 60 days, you will begin paying copays. For days 61 through 90, you are responsible for a $335 copay each day. Then for days 91 through 150 you will have a $670 copay each day.
After you have spent at least 60 consecutive days outside of the hospital, your benefit period ends. If you later have to go back for another impatient stay, you will have to pay the Part A deductible again.
Just like Part A, Medicare Part B has a deductible and cost sharing amounts. The 2018 Part B annual deductible is $183. This deductible is different than the Part A deductible in the way that you pay it once annually instead of potentially paying it multiple times in one year.
Once your Part B deductible has been met you will begin to pay a coinsurance. Medicare Part B covers 80% of your medically necessary outpatient services and your coinsurance is the 20% that Medicare doesn’t cover. There is no cap to how much you will pay out-of-pocket each year.
Costs with Medicare Part D
As far as costs go, Medicare Part D plans are all different. With some Part D plans, you might have to reach a specified annual deductible. Like we mentioned above, each Part D plan is able to dictate how much their copay prices will be for each tier of medication.
This means that before you enroll, you will need to review the plan’s drug formulary to figure out which tier your medications are classified as. Then check the copay amount for those tiers to prepare yourself for your future expenses.
What Doesn’t Medicare Cover?
There are a few things that Original Medicare doesn’t cover. Benefits such as dental and hearing are not covered. Also, ironically, Medicare doesn’t cover vision.
When it’s said that Medicare doesn’t cover vision, it really means that Original Medicare doesn’t cover routine services for vision. Regular eye exams throughout the year are is an example of what Medicare doesn’t cover. It also doesn’t pay for your glasses except after a cataract surgery.
When it comes to glaucoma or any other disease of the eye, Medicare treats that like any other health condition and covers most medically necessary treatments.
First, we should mention that nearly all of these plan options have a monthly premium that you will have to pay in addition to your Original Medicare premiums. Now let’s look at the coverage.
Also known as a Medicare Supplement plan, a Medigap plan is meant to help you pay for the gaps within Medicare. These are the gaps within Medicare that we described earlier: your deductibles, coinsurance, and copayments.
Most states offer ten standardized Medigap plans. Plan F is the most comprehensive plan available today. It covers all gaps in Part A and Part B. Because it offers the most coverage, it usually is the most expensive option as well.
Plan G is the second most comprehensive. The only thing it doesn’t cover that Plan F does is your Medicare Part B deductible of $183. Even with paying the Part B deductible, some people are able to save money when enrolled in Plan G versus Plan F. This happens because Plan G’s premium is usually less expensive than Plan F’s.
Medicare Advantage Plans
Medicare Advantage plans are another route you go to help you cover the gaps in Medicare. These are private plans that cover your benefits instead of Medicare. Another name you might hear Medicare Advantage plans being referred to as is Medicare Part C.
Like Medigap plans, Part C plans have monthly premiums. However, some Medicare Advantage plans have a $0 monthly premium. It can be a great option to consider if you can’t afford a Medigap plan.
One key thing in particular that Medicare Advantage plans have that Medigap plans don’t is a network. When enrolled in a Medicare Advantage plan, you will most likely need to stay within a specified network of providers when receiving your medical treatment. This means you have less choices for providers than you would if you enrolled in a Medigap plan.
Medicare Advantage plans are also allowed to include coverage for ancillary things like dental, vision, hearing, and gym memberships. Each plan has a summary which you can consult to see what sorts of provisions for these are included.
There are also stand-alone Dental, Vision, and Hearing (DVH) plans that a glaucoma patient could benefit from. Similar to Medigap and Medicare Advantage plans, DVH plans are provided my insurance carriers. To learn more about how you can apply for a stand-alone DVH plan, click here.
Tips for Choosing the Right Medicare Plan
The rule of thumb when choosing a Medicare plan is pick the type of plan that is best for you, not your neighbor. Just because your friend down the street has one type of plan, doesn’t mean that you should get the same type.
Evaluate the things that are most important to you in an insurance plan and apply those to the Medicare plan options you have. That way you can outweigh the good with the bad and pick the option that is most suitable for your personal needs and budget.