Doctors usually treat macular degeneration with injectable drugs they administer into the blood or into the eye itself. Medicare partially covers some of these treatments, including various injections, under certain conditions.
Macular degeneration is an eye disease that causes a person’s central vision to blur. It occurs when the macula, part of the retina, becomes damaged due to aging. The condition is a significant cause of vision loss, affecting around
This article looks at whether Medicare covers treatments for macular degeneration, how much they cost, coverage exclusions, and how to get help paying for macular degeneration treatment under Medicare.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Part B will typically contribute to both screening and treatment for macular degeneration if a healthcare professional deems them medically necessary. Medicare Part B covers certain doctor services, medical supplies, and outpatient care.
According to Medicare, in an outpatient setting, a person will generally need to pay a 20% copayment of the amount it approves after they have met the Medicare Part B deductible. Medicare typically covers the remaining 80% of the approved cost of treatment if it satisfies the necessary conditions. In rare cases, a person may need to pay excess charges.
The costs may vary if someone is enrolled in a supplemental Medicare plan. In these cases, such as on a Medigap plan, a person may only have to pay the deductible amount or may not have to pay any funds out of pocket.
Medicare may agree to cover the following injections for macular degeneration:
Various factors may affect the specific amount a person may have to pay for treatment and whether and how much Medicare may agree to cover.
- the amount a person’s doctor charges
- the type of medical facility where a person receives treatment
- other insurance the policyholder has
- where a person receives their tests or services
- whether a person’s doctor accepts Medicare assignment
- whether a doctor recommends a person get services more often than Medicare will cover
- whether a doctor recommends particular treatments or services that Medicare does not cover
The cost of treatment for macular degeneration varies greatly, depending on the specific medication a doctor injects, the amount and frequency of injections a person requires, and other factors.
The amount a person can expect to pay can vary depending on factors, including the specific medication a patient will receive, the medical setting where treatment occurs, and others.
If the doctor or supplier of the injectable treatments for macular degeneration accepts Medicare assignment, they are a Medicare participating provider. This means the doctor or supplier will accept the amount Medicare has approved as full payment for the treatment.
Medicare states that the insured person receiving the treatment must pay 20% of this approved amount.
To best understand the costs of treatment and how various factors impact it, it is best for a person to discuss their options with their insurance provider before scheduling treatment. The provider can give an estimate based on a person’s specific situation.
Some questions to ask may include:
- What percentage of coverage does the policy offer?
- What amount will Medicare agree to cover?
- If a policyholder requires additional treatment, will coverage change?
- Can a policyholder receive a second opinion?
- What deductible must the policyholder meet?
- What is the out-of-pocket maximum for the policy?
- Is the policyholder responsible for coinsurance or copayments?
- Are all the medical team members in-network?
- Which treatment facility types does the policy cover?
- Which medications or treatments does Medicare not cover?
Medicare Part B generally does not cover the following, which may relate to treatment for macular degeneration:
- routine vision services
- home safety items, such as grab bars
- services that are not medically necessary, such as cosmetic surgery
- long-term care in facilities such as nursing homes
Because it does not cover routine vision services, a medical health provider must deem it medically necessary for a person to receive screening and treatment for macular degeneration in order for Medicare to cover it.
For more information on this topic, a person can contact Medicare directly and speak with a representative.
Ahead of an appointment with a representative, people can use this Medicare search tool to learn more about its macular degeneration coverage.
Individuals can also speak with a doctor or healthcare professional about their options under Medicare.
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare states that it typically covers up to 80% of the cost of specific injectable treatments for macular degeneration under Medicare Part B if a healthcare professional deems them medically necessary.
Costs and approval can vary depending on a variety of factors. These include the amount a doctor charges, whether the doctor accepts Medicare assignment, the type of facility where treatment takes place, and the specific treatment type.
A person will usually have to pay 20% of the Medicare-approved amount of treatment after meeting the deductible. This amount can vary greatly depending on the medications a doctor uses, whether it takes place in an outpatient setting, and treatment frequency and duration.
It is best for a person to discuss coverage with Medicare before they schedule treatment. They will need to ensure the doctor or healthcare team, specific treatment, facility, and other criteria are a match for Medicare approval, as it may refuse coverage in particular cases or cover more or less of the cost.