Insurance Questions

Helping you make sense of eye care insurance plans

Insurance plans and coverage are like ocular lenses, no two are alike! Please verify your insurance coverage before your appointment.

***Every patient is responsible for the balance of any charges not covered by their insurance. ***

NOTICE: Please be aware that many insurance companies are now requiring authorization from your Primary Care Provider prior to being seen by a specialist.  Insurance companies will NOT cover the expenses of your appointment if you are required to obtain this authorization and do not.  It is your responsibility to provide a paper copy of this authorization on the day of your appointment; a verbal authorization will NOT be accepted by your insurance company.  We recommend that you call your insurance company to verify the requirements of your policy.
You may call the phone number on the back of your insurance card if you have any questions.

 

Is Dr. Memmen a provider in my network?

Dr. Memmen is an in-network provider for most insurance plans in Northeastern WI including, but not limited to, the insurace companies listed below.

This list DOES NOT mean that your individual plan has appropriate coverage of all costs incurred during your appointment. Always check with your insurance company to confirm what costs they cover and the amount of your co-pay, deductible and co-insurance.

If you have any questions, you may either call the phone number on your insurance card or

NOTICE: If you call the phone number on your insurance card and request the insurance representative to do an “in-network” search, be sure to request a “state-wide” search. Occasionally, the search provided to you will have an “x-mile” radius restriction. If you live further than 50 miles from Dr. Memmen’s Appleton or Green Bay offices, they may not list him as an in-network provider, when, in fact, he is!

In-Network Insurance Companies

  • Medicare
  • All Medicare Advantage Plans
  • Affinity
  • Anthem Blue Cross Blue Shield
  • Arise
  • Bellin Health – Theda Care – PPL PHO
  • CoreSource
  • Humana
  • Health Systems International
  • Managed Health Services
  • Network Health Insurance systems
  • Bellin/Physicians Partners Ltd:
    • Bay Area Medical Center
    • Cypress Benefit Administrators
    • Galaxy Health Network
    • GEHA
    • Health EOS
    • Health Payors Organization
    • Healthcare Inc
    • Health EOS PHCS Savility Network
    • Independent Care Health Plan (icare)
    • Integrated Health Plan
    • Oneida Nation
    • Oshkosh Corporation
    • PlanCare America
    • ppoNext
    • Prime Health Services
    • Pyramid Life – Todays Options
    • Star Healthcare Network
  • Tricare
  • Trilogy Health Insurance
  • United Health Care
  • WEA Trust
  • WPS Health Insurance (Wisconsin Physicians Services Insurance Corporation)

Why is my co-pay for an appointment with Dr. Memmen more than it is with my primary care physician?

Many insurance companies have different co-pay amounts for physician categories. Dr. Memmen is a specialist and the co-pay amount listed on your card may be more than an office visit with your primary care physician. An emergency room or hospital visit copay will typically be even more.

All of these co-pay amounts are agreed upon by you and your insurance company and may be listed on your insurance card. If they are not listed, you may call the phone number on your insurance card to determine your co-pay amount. Please be sure you are aware of and are able to pay your co-pay at the time of your appointment.

Why do I have to pay another co-pay? I was just in to see Dr. Memmen last week.

When you purchase medical insurance, you and your insurance company agree to specific terms and conditions. Your insurance company considers each appointment with Dr. Memmen as a separate office visit and, therefore, they require you to pay a co-pay at every appointment.

Dr. Memmen will never suggest an unnecessary follow-up appointment. When he advises you to return whether in a few days or a week or a month, he does so because it is medically necessary to keep your eyes healthy.

Will my insurance cover my eye surgery?

Every insurance plan is different and, unfortunately, can be very confusing. It is up to you, as the patient, to contact your insurance company to guarantee they will cover your surgery costs. Our staff will be happy to provide you with the information you will need when communicating with your insurance administrator. One of our staff members is available if you have any questions.

Keep in mind: insurance plans with deductibles will require you to meet that deductible before they begin covering expenses.

What is a refraction?

Remember that test you had with our medical staff when they asked which lens made you see more clearly? “Better one, better two? Better three, better four?”

A refraction is a necessary test that collects information about your eye’s ability to focus light on your retina. Based on this information, Dr. Memmen can then determine what adjustments are necessary to achieve your best visual acuity.

The test may show that you need a prescription for glasses or that your prescription has changed. It may show that your eye does not require any correction. A refraction may also discover a more serious underlying problem needing further investigation.

Think of a refractive test like a routine blood test ordered by your primary physician. Sometimes your blood test comes back with results of concerning white blood cell counts or glucose levels or high cholesterol. Sometimes your blood test shows that you are in perfect health. Either way, the doctor charges your insurance company for this test.

We also charge your insurance company for the refractive test. The difference is, unfortunately, many insurance companies do not cover the cost of a refraction and Medicare never covers this cost.

Health insurance financial decisions do not always make sense. Many insurance companies have never covered the cost of refractions. However, if you ask any ophthalmologist, they will all give you the same answer: a refraction is a medically necessary test for your overall eye health. So, even though your insurance company does not consider the test “medically necessary,” your professional ophthalmologist does!

Contact your insurance company to verify coverage for your refraction.

An example of insurance coverage similar to the “Refraction Dilemma”:
Macular Degeneration is the #1 cause of blindness in the United States. The use of anti-oxidant nutritional supplements and Omega 3 supplements has been shown in multiple studies in multiple countries to decrease macular degeneration up to 50%.

Medicare believes the use of these supplements is so important that ophthalmologists are required to report that they have counseled their patients to use them. However, Medicare will NOT cover the cost of these supplements…does that make any sense to you? No? It doesn’t make sense to us either!

What does a Vision Plan cover?

Many insurance plans offer an additional “Vision Plan” to your medical insurance for an extra monthly premium/cost. These vision plans cover “routine eye exams” and may also include benefits for glasses and contacts.

If you have a medical diagnosis, your vision plan will not cover the costs of your eye exams, even your annual comprehensive exam. (See “What’s the difference between a “Routine Eye Exam” and a “Medical Eye Exam?”) So, unless you have a family that is utilizing the benefits provided by this plan or you are using the glasses/contact benefits, you may be paying an extra premium for services you can’t even use.

Contact your insurance agent for more information about your individual plan and how it applies to your medical care.

What's the difference between a Routine Eye Exam and a Medical Eye Exam?

Some medical insurance plans offer a “free” annual eye exam as part of your benefits. This service is covered by your insurance provider if it is a routine exam only.

A “Routine Eye Exam” is when your eyes are examined by an optometrist or ophthalmologist and you have no medical diagnosis. Your refraction may show that you need a prescription for glasses to provide your best visual acuity (the clarity or sharpness of vision) or that you don’t need a prescription at all. Myopia, hyperopia and presbyopia are conditions that only effect your visual acuity, can be treated with a prescription for glasses and are not considered a medical diagnosis.

You may schedule a “routine exam” with your doctor and during the course of that exam, you share a problem or concern with your doctor or the doctor finds a medical diagnosis (like dry eye, flashes or floaters, diabetic retinopathy, macular degeneration, conjunctivitis, cataracts, glaucoma, etc.). This medical diagnosis turns your “routine exam” into a “medical eye exam.” Your insurance company now considers this part of your medical insurance plan and the charges are applied to your deductible or co-insurance.

Contact your insurance agent for more information about your individual plan and how it applies to your medical care.


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