Medicare Beneficiary Agreement

(Medicare only – used if Medicare will deny payment of services)

Medicare will only pay for services that it determines to be reasonable and necessary under section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. Medicare is likely to deny payment for the following procedures as non – covered procedures: {Refraction (92015), Anterior Segment Photos (92285), Spectacles or Contact Lenses are non-covered items by Medicare other than post-operative cataract extraction,

I have been notified by my physician, at Hopewell – Lambertville Eye Associates, that he or she believes that, in my case, Medicare is likely to deny payment for the service(s) identified above, for the reason(s) stated. If Medicare denies payment, I agree to be personally and fully responsible for payment.

TO ALL MANAGED CARE – VISION PLAN and Medicare PATIENTS

Please be aware that your benefits are limited and that you will be responsible for specified payments of your examination, spectacles, and / or contact lenses. (i.e. co – pays and non-covered procedures) that are not covered by your carrier.

These plans are vision only (annual – wellness – preventative health care related). These are not medical plans. Medical concerns, in general, will require a return visit with a referral. Certain procedures may not be covered by your plan such as corneal topography, automated screening visual fields, and dilated retinal examination. A dilated retinal examination (the use of drops to fully examine the internal eye health) is considered the most important part of the examination. **Additionally, contact lens fitting and progress evaluations are not considered as part of the annual examine as defined by vision policies. Therefore, there will be an additional charge for lens evaluations as well as any lens refit (if required).

Eyeglass Benefits

Please be aware that managed care vision plans such as EyeMed, Spectera, VSP, Davis and others, have a specified and limited eyeglass frame selection and options. If you are unclear with your benefits, our staff will assist in determining your benefits or you are encouraged to call your provider.

Hopewell – Lambertville Eye Associates, by contract with the various vision plans, have a selection of frames or contact lenses specified by your carrier. However, we feel that as a courtesy to our patients, we have extended this benefit above and beyond what we are contracted to offer. All plans have a “retail” allowance in lieu of their specified frame selection. Please check with our staff if this is an option.

Contact Lens Benefits

Managed care vision plans such as EyeMed, Spectera, VSP, VBA, NVA and others, have very limited benefits for contact lens materials. Professional fees are separate and not covered by the vision plan – therefore these fees are the responsibility of the patient or their guarantor. Material benefits by a vision plan is for contact lenses or eyeglasses not both. If contact lenses are purchased through a vision plan, our office offers courtesy discount on the purchase of eyeglasses. This discount is not part of the vision plan, but a courtesy extended to our patients by our office.

Professional and Products Fees

All additional professional and product fees due, inclusive of co-payments, charges on eyeglasses or contact lenses are required to be paid in full prior any order processing.

The patient understands the all above statements and will assume the listed payment responsibilities.