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Vision Plans vs. Medical Insurance
Difference between Vision "Insurance" and Medical Insurance is one of the most confusing issues patients face in any optometrist's office.
Regular eye examinations are important to maintain your vision for your lifetime. It is important that you be aware of your insurance benefits and how they apply to your visit.
This will help you understand how your visit is submitted to your health insurance or vision insurance for your visit. Benefits may vary based upon the reason for your visit. Please be aware that insurance coverage is a relationship between you and your insurance provider. And as per your insurance, an authorization from them does not guarantee payment so please be aware of your plan benefits.
Routine Eye Examinations Covered By Vision Plans:
A “routine wellness eye exam” takes place when you come for an eye examination WITHOUT any underlying medical condition which affects the eye (like diabetes, dry eyes, eye infections, glaucoma, cataracts etc...). The doctor screens the eyes for disease and will check your vision. A routine eye exam covers basic eye care (nearsightedness, farsightedness, normal astigmatism, glasses and/or contacts IF necessary). It is always assumed that NO known medical and/or eye conditions exist.
If a medical symptom or diagnosis exists, vision insurance will generally not cover the visit. Generally, once a patient has a medical diagnosis (for example Diabetes, Macular Degeneration or Cataracts) - wellness or routine exams are no longer done and the Vision Plan does not cover the visit but the Medical Insurance usually does. The Vision Plan can be used at that point to to purchase eyeglasses or contact lenses but, it is no longer used for the eye exam.
Vision wellness insurance plans are designed to cover ONLY updates in glasses and contact lens prescriptions and a health wellness screening. IT DOES NOT COVER any other issues with the eye, such as allergies, dryness or infections. It also does not cover any treatment for headaches, cataracts, macular degeneration or glaucoma. In addition, it does not cover any monitoring for patients on high risk medications, such as Plaquinil, or diabetic check-ups. All of these other medical conditions and more are usually covered by your medical insurance. Unfortunately, due to the rules of your insurance company, we sometimes have to bring patients back for a separate visit from their annual vision plan's wellness exam to treat their medical concerns.
The doctor cannot tell if any medical eye conditions exist before you are thoroughly examined.IF during your routine eye exam the doctor encounters a medical eye related problem, it is your Medical Insurance that will need to cover the additional procedureseven though a Vision Plan may also be in effect to be used towards your glasses and/or contact lenses. This is often due to the fact that certain findings require specific counseling, documentation, follow up care, regular monitoring or referral to a surgeon. These medically related visits are NOT COVERED by your Vision Plan. In addition if we do file the exam with your medical insurance, you can still use your Vision Plan materials benefits towards the purchase of glasses or contact lenses based on your plans allowances and necessity.
It is important that you understand that your Vision Plan (VSP, EyeMed, VCP, Spectera or Davis Vision) covers ROUTINE / WELLNESS eye care only.
Examples that will necessitate your visit being submitted to a Vision Plan as a routine wellness vision exam include:
Basic eye exam for Nearsightedness, Farsightedness, Astigmatism, Presbyopia/Need Reading Glasses or Bifocal Prescription
Glasses / Contact Lenses Purchase
Medical Eye Examinations
Covered By Medical/Health Insurance Plans:
Exams for medical care which are for evaluation of a medical-related complaint or follow up / re-evaluation of an existing condition are examples of an eye examination that would be billed to your medical insurance.
Using Medical / Health Insurance may be subject to fulfilling unmet deductibles and/ or copays before plan will pay towards your visit. Please check with your individual insurance plan for more details.
Examples that will necessitate your visit being submitted as a medical exam include but may not be limited to:
Dryness of the Eyes
Redness of the Eyes
Floaters and/or flashing lights
Referral from outside physicians
High risk medications (auto immune drugs like Plaquenil for lupus or arthritis, systemic illness treatment like insulin for diabetes)
Eye muscle imbalance
Trauma To The Eye
Loss of Vision
Metal (or Something Else) in the Eye
Stye on Eyelid
* Please note that if you have Diabetes, the visit will be coded as a “medical eye examination” because Diabetes is the Number ONE Cause of Blindness in the US and the Doctor must take additional steps and time during your eye exam to properly determine if your Diabetes is affecting your eye health and / or your vision. Most eye health issues DO NOT cause any symptoms until its too late.
The purpose of your visit will determine which insurance benefit will be used.
If your doctor determines that your problem falls under the category of a “medical eye examination”, your visit may be billed as a medical exam instead of a routine vision exam, which will be subject to co-pays and deductibles according to your medical insurance plan. You will then have the option to pay out of pocket for your refraction (glasses/contact lens prescription) or schedule a return appointment, using your applicable vision insurance.
Materials such as eyeglasses and contact lenses are NOT covered by medical insurance.
Medical Insurance Accepted / In-Network (We Submit Claim For You):
Medical Insurance - ACCEPTED AS OUT OF NETWORK (Patient Pays Doctor's Office and Then Submits The Bill to Their Insurance Company Themselves to Be Applied to their Deductible OR for Reimbursement):
Blue Cross/ Blue Shield
Vision Plans Accepted / In Network (We Submit The Claim For You):
Vision Plans Are Used For The Determination and Treatment of Sight Correction...and also used towards the purchase of materials for vision correction (Glasses OR Contact Lenses)...they do NOT pay for evaluation or treatment of medical eye conditions like cataracts, diabetic eye evaluations, dry eye, red eyes, macular degeneration etc
Aetna Vision Plan
Metlife Vision Plan
Vision Plans ACCEPTED AS OUT OF NETWORK - Patient Pays Doctor and Then Submits to Their Vision Plan Themselves for Reimbursement):
Humana Vision / VCP
If you don't see your Medical or Vision Insurance Plan - please call our office to find out if we are an IN Network or Out Of Network Provider
We DO Add Plans All The Time!
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