The University of Pittsburgh Medical Center (UPMC) offer Medicare Advantage plans that include vision benefits. Their plans are available across most of Pennsylvania and in some counties in Ohio.
Original Medicare plans do not generally include vision and eye care benefits.
Medicare Advantage plans provide all the benefits of original Medicare’s parts A and B but often include additional coverage for vision, dental, and hearing services.
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.
UPMC are one of the Medicare-approved private insurance companies able to administer Medicare Advantage, or Medicare Part C, plans.
All private companies who administer these plans must follow Medicare’s rules on coverage. However, they may also include additional benefits and provider network rules.
There are four common types of Medicare Advantage plan, which are as follows:
- Health Maintenance Organization (HMO) plans: HMO plans have a healthcare provider network that a person must use for their care. Some HMO plans allow a person to use out-of-network providers, but the out-of-pocket expense can be significantly higher.
- Preferred Provider Organization (PPO) plans: PPO plans also have a provider network, but individuals can opt to use out-of-network services, though costs may be higher.
- Private Fee-for-Service (PFFS) plans: With PFFS plans, providers decide how much they and the person will pay for healthcare services. Some, but not all, plans have provider networks.
- Special Needs Plans (SNPs): SNPs are limited to those with specific health conditions. These plans provide tailor-made benefits to meet the needs of the individual.
HMO and PPO plans
UPMC offer HMO and PPO plans, known as UPMC for Life. Both include vision benefits.
The UPMC PPO plan offers benefits in and out of a provider network. The UPMC HMO plans use a network of healthcare providers, and a person can visit out-of-network providers only if they need:
- emergency care
- out-of-area urgent care
- out-of-area kidney dialysis
UPMC also offer an HMO SNP plan. This plan is for those eligible for both Medicare and Medicaid.
These plans include many additional benefits, including vision care and coverage for prescribed medications.
Many Medicare Advantage plans offer vision care, including UPMC for Life.
Their plans include a routine vision allowance that pays for eye exams, frames, lenses, and contact lenses.
A person can receive one exam and a cash benefit for eyewear every 1 or 2 years, depending on their plan. Different plans also have different cash benefit amounts.
People do not need to visit an in-network healthcare provider, but if the provider is in-network, they will send the bill directly to UPMC for payment up to the plan limits.
If an individual visits an out-of-network healthcare provider, they will normally pay out of pocket at the time of the appointment. They can then send a claim to UPMC for reimbursement within the vision allowance.
People who undergo cataract surgery cannot use the routine vision cash benefit for their glasses, as special rules apply.
The cost for a Medicare Advantage plan with vision cover depends on where a person lives and can include:
- in-network and out-of-network deductibles
- maximum out-of-pocket costs
This table shows some costs for policies in Lancaster, PA:
|UPMC for Life HMO Premier Rx||UPMC for Life PPO Rx Enhanced||UPMC for Life Complete Care (HMO SNP)|
|Premium||$0||$60 per month||$0|
|Health deductible||$0||$0 in-network|
|Out-of-pocket maximum||$7,550 in-network||$7,550 in-network|
$11,300 combined in- and out-of-network
|Primary doctor copayment or coinsurance||$0||$5 copayment in-network|
40% coinsurance out-of-network after deductible
|Specialist copayment or coinsurance||$40 copayment per visit||$40 copayment in-network|
40% coinsurance out-of-network after deductible
A person can enroll in a UPMC Medicare Advantage when they first become eligible for Medicare during their initial enrollment period (IEP).
The IEP runs for 7 months. It begins 3 months before a person turns 65 years of age, continues through their birth month, and ends 3 months after.
A person can enroll during two other periods throughout the year.
The first is during the open enrollment period, which runs from October 15 to December 7 each year. A person can add or drop a Medicare Advantage plan during this time.
The second is during the Medicare Advantage open enrollment period, which runs from January 1 to March 31 every year. During these months, a person can make only one change to their coverage, such as moving from one Medicare Advantage plan to another.
People living in many parts of Pennsylvania and in some counties in Ohio may join a UPMC Medicare Advantage plan.
UPMC do not offer Medicare Advantage plans in other areas of the country.
A person can look for a UPMC Medicare Advantage plan on the company’s website by entering their zip code. Alternatively, they can use the Medicare plan finder tool to search all available Medicare Advantage plans in their area.
UPMC sell Medicare Advantage plans in many areas of Pennsylvania and in some counties in Ohio. They have HMO and PPO plans available.
They offer added benefits, including vision care. People may have an eye exam every 1 or 2 years. People also get a vision cash benefit to help pay for eyewear. The amount and how often they get an exam depends on the policy.
Each Medicare Advantage plan has costs that include a monthly premium, deductibles, and copayments. The costs will depend on a person’s location.