Vision and Medical Insurance at the Optometrist

Vision and Medical Insurance at the Optometrist

Insurance can get pretty complicated. We all wish health insurance was a little more straightforward, a little less expensive, and provided us better benefits. While WH vision can’t help with the last two, we would like to help make some sense of your insurance as it relates to your eyes.

Vision insurance is not actually insurance. Vision insurance should more properly be called a discount program. Most vision plans cover a “routine” vision exam once a year. Typically there will also be a materials benefit on most insurance plans. Materials benefits are a set amount of money that the plan provides towards the purchase of optical goods. Once you exceed that set amount of money you are responsible for the remainder of the cost of goods. Most materials benefits are split into a frame benefit and a lens benefit. The lens benefit is applied to either contact lenses or the lenses in your spectacles. Some vision plans will also pay a portion of the contact lens fit or assessment. Some vision plans renew annually from the time you use the benefits and some start over with each calendar year.

Most optometrists also accept major health insurances like Cigna or Medicare. Anything that is not routine is covered by medical insurance. Common examples include diabetic eye exams, pink/red eye, cataracts, dry eye, and eye injuries. Health insurances usually do not cover the portion of the exam that involves finding a glasses or contact lens prescription.

Many patients opt for retinal imaging in their exams. These screening photos are not covered by medical or vision insurance in the vast majority of cases.

Do you need to have insurance to see an eye doctor? No, you definitely don’t. Most eye doctors would agree that for routine eyecare you do not save a lot of money by having vision insurance. Eye exams are reasonably priced, and glasses and contact lenses can be adjusted for most budgets. The math shows that you essentially pay the same price in cash as you do with vision insurance when you include the cost of the vision insurance. This is a large generalization, but is true in most cases.

Just as in any healthcare setting, insurance is both a nightmare and boon for eye care providers and patients. Given the choice, most eye care providers would prefer not to take any insurance, but it is seen as a necessity for two reasons. One, accepting insurance helps bring patients into the office. Patients generally go where their insurance is accepted (as they should), and as eye doctors we want to see and help patients. Two, when patient’s have medical conditions requiring in depth care bills can pile up quickly, and accepting insurance can help patients financially. One of the few things that I like about vision insurance plans is the medically necessary contact lens clause that allows me to fit specialty contact lenses for the patients that can really benefit from them.

If you have any other questions about your vision or health insurance and how it relates to your eye care give us a call. And don’t forget to use your vision benefits before they expire this year!


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