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Archelle Georgiou: "I See," Said The Blind Man…How Health Reform Will Work

July 7th, 2009, 07:07 pm admin Leave a comment Go to comments

As President Obama continues to push for health reform, he elegantly states that we need a “uniquely American” system; But Americans want specific answers regarding how health reform and a public plan option will really work. Who will decide what is covered… and what is not? Can we be reassured that the system will be designed to promote better health? Who will enforce the rules? How will the system impact people when they are most vulnerable?

Since Medicare is a “uniquely American” system that is likely to be the foundation of any new government run health care option, Americans can get a glimpse of the future by better understanding the CMS coverage rules and processes for one specific area — eye care and vision services.

How Does Medicare Work?

1) Medicare does not pay for routine eye exams and eyeglasses. However, the rationale for this decision is unclear since poor vision is a leading cause of falls in the elderly and the National Eye Institute estimates that over 15 million seniors over age 60 are either near- or far-sighted.
Bottom line: The government decides what is covered, and decisions are not necessarily aligned with prevention and patient safety.

2) Medicare does pay for one pair of eyeglasses or lenses after cataract surgery since “Medicare Part B covers prosthetic devices needed to replace an internal body part or function… including corrective lenses after cataract surgery.”

Based on this language, I assumed that my mother’s glasses would be covered after her corneal transplant surgery. While the lens and the cornea are different structures in the eye, both surgeries replace an internal body part and are essential for sight. However, during a call to the Medicare intermediary, the customer service agent as well as the supervisor simply read an excerpt from the policy language that said eyeglasses are only covered after cataract surgery. We called CMS directly. Two weeks later, we received a letter with the same response from a health insurance specialist.
Bottom line: Coverage decisions are narrowly defined and policy-driven, not health-driven.

3) Neither the Medicare intermediary nor CMS explained that we had the option to appeal this decision. Yes, the Medicare handbook and the CMS website outline a five-level appeal process but it can only be initiated in writing and only after a claim is submitted (and denied) which puts members at personal financial risk. This approach is significantly more onerous than the highly regulated practices in private plans that offer the option of written or verbal appeals before a service is rendered and clearly articulate the appeals process in all phone and written communications with members.

It seemed futile to appeal, and the practical reality was that, without glasses, my mother couldn’t even see well enough to read the appeal process instructions or write the letter.
Bottom Line: CMS makes the rules and creates an effective bureaucracy that enforces the rules. Consumers have little recourse. Period.

We paid $400 for my mother’s new glasses. But for the millions of individuals who cannot afford a pair of glasses, I hope this article lets them “see” how health reform will really work. A public plan option may be “unique” but not necessarily “American.”

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