At SightHealth Primary Eyecare, we receive this question on a daily basis. We understand that this is a confusing topic, particularly in the world of eye care. We’ll help you understand the difference between the two kinds of insurance so you can make an informed decision.
Medical insurance, or health insurance, will generally cover eye-related medical problems discovered during an optometrist’s eye exam. Some examples include:
- Eye Strain
- Blurry Vision Not Related to Your Prescription
- Dryness & Irritation
- Eye Infections
- Eye Diseases (Glaucoma, Cataracts, Macular Degeneration)
- An Eye Emergency (Retinal Detachment, Eye Injury)
- Dry Eyes
- Eye Allergies
- Diabetic Eye Disease
This type of visit should be covered the same way any visit to a medical specialist is covered. Your medical insurance will be billed for the eye exam even though a vision plan may be in effect, since you are being treated for a medical condition.
Expect to pay any medical insurance copays and deductibles at the time of your exam. If we file your claim with your medical insurance, you can still use your vision plan benefits towards the purchase of frames, lenses or contact lenses, all depending on your plan’s allowances.
However, unless you have VSP Vision Insurance, you cannot use your vision and medical insurance for a joint exam on the same day. That said, we can always schedule your medical and vision visits on separate days.
- Are you considering getting a new pair of glasses?
- Do you need to renew your contact lens prescription/order?
- Do you want to evaluate which pair of lenses will improve your daily activities?
Vision insurance covers routine eye exams and provides allowances towards new frames, eyeglass lenses, and contact lenses.
A routine eye exam includes an undilated view of your eye, slit lamp exam, and a refraction test (nearsightedness, farsightedness, and normal astigmatism) to determine your contact lens and eyeglass prescriptions. Certain plans may provide a limited contact lens evaluation benefit while others will not. Not all vision plans cover dilation, so keep this in mind before your optometrist determines that one is required.
If your routine eye exam reveals a medical condition or disease related to your eye, or if the exam is due to a pre-existing condition such as cataracts, glaucoma, diabetes, dry eye, etc., then your visit won’t be covered by vision insurance, but rather medical insurance.
To summarize, vision insurance generally covers:
- New Glasses
- New Frames
- Routine Eye Exams
- New Single Vision or Progressive Lenses
- Blurry Vision Related to Updating Your Prescription
None of these, however, will be covered by medical insurance. Though seeing clearly enables us to enjoy our daily activities, it is not considered a medical necessity.
Regardless of your insurance, most vision plans don’t cover 100% of expenses. You should, therefore, expect some out-of-pocket costs. This may include copays, deductibles or a percentage of costs that you will have to pay out-of-pocket as required by your insurance policy.
We strongly encourage you to contact your insurance company before your appointment so you know your plan’s specific details. After that, for any further information related to your medical insurance and eye health concerns, contact SightHealth Primary Eyecare at St Johns today. We will do everything we can to help you better understand your policy, because the more information you have ahead of time, the fewer surprises you’ll have at the time of the exam.