Many people are confused if vision care is covered by their health insurance plan. Here is a commonplace scenario – you see your eye doctor because your eyes are itchy and dry and you suspect you have dry eye. While you’re there, the doctor suggests you have a routine eye exam for visual acuity to make sure your correction hasn’t changed. You are surprised when you receive your insurance estimate of benefits, indicating the dry eye portion of your exam is covered, but you are responsible for the full cost of the routine eye exam! Insurance companies define a routine or annual vision exam as an office visit for the purpose of checking vision, screening for disease, and/or updating eyeglass or contact lens prescriptions.
Routine exams, eyeglasses, and contact lenses aren’t covered by health insurance nor Medicare, however, many people have an ancillary vision care plan. This plan may be an add-on to regular health insurance or can be purchased separately. It provides partial coverage to offset these costs. As with medical plans, large providers such as Vision Service Plan and EyeMed have two tiers of coverage – in-network and out-of-network. For the latter, out-of-pocket costs are higher and you need to pay for services/goods up front, then submit the receipts for partial reimbursement.
Vision Benefits for covered members typically include:
- Routine vision exams
- Prescriptions for eyeglass lenses and/or contact lenses
- Allowances and/or discounts for eyeglass lenses or contract lenses and frames
Medically Covered Eye Care Costs
Here is another typical scenario – you go to a provider who accepts your vision care insurance. During your partially covered routine exam, the optometrist detects a possible issue with your ocular pressure. You are advised to visit an ophthalmologist, whose services will be considered medically necessary, and therefore covered by your primary health insurance plan. Treatment of eye conditions, diseases, medically necessary surgery, and related prescriptions are covered, subject to your deductible and co-pays. In another scenario, you visit a participating provider in your vision network for a routine vision exam and he or she discovers an eye health condition and runs some diagnostic tests. These are billed to your medical insurance, as are subsequent visits. It’s important to keep in mind an eye doctor who participates in your vision care network may be out of network under your health insurance plan, so you need to ask before approving any tests.
Vision Service Plan (VSP)
VSP Vision Care (VSP) is the largest vision insurance company in the U.S., although, it also operates in Australia, Canada, Ireland, and the U.K., with about 80 million subscribers worldwide. VSP subscribers receive optical services at greatly reduced prices from participating VSP providers. You are responsible for co-payments, but can optimize your savings by using a Health Savings Account (HSA) for out-of-pocket costs.
Buying Online Glasses and Contacts
It can get complicated using vision care benefits when you purchase glasses online, but it is possible. You need to check with each of the online companies to see which vision care plans they accept, both in and out-of-network. For example, Eyeconic.com accepts VSP, MetLife, and Cigna Vision. You could consider the option of buying online out-of-network, in which case you’ll need to pay up front and submit receipts to your vision care provider. It is essential to do price comparisons between local in-network opticians, out-of-network online retailers, and regular promotions offered online. A local optician will always have significantly higher prices than an online retailer like Zenni Optical.
The EyeQue Personal Vision Tracker enables you to obtain spherical, cylindrical and axis figures – the same type your eye doctor uses to generate a prescription. You can take these numbers and order eyeglasses or contacts online. Just keep in mind this doesn’t replace a routine eye exam, which may uncover potential eye health conditions.
Finding Doctors in your Plan
The best way to see if doctors or facilities are in your network is directly on the vison insurer site (e.g. VSP, EyeMed, etc.) If you are looking for a one-stop online search to look at reviews and check if a doctor is in-network, ZocDoc is a good option. The ZocDoc listings may not be as up-to-date as the vision care plan site, so it’s always best to call the doctor’s office directly to check if they still participate.
The Importance of Routine Eye Exams
The American Optometric Association recommends a comprehensive eye exam every 2 years for adults ages 18 to 60, and annual exams for people ages 61 and older. A family history of eye disease (e.g. glaucoma, macular degeneration), diabetes or high blood pressure, and recent eye injuries or surgeries, are exceptions to this rule. In such cases, an annual comprehensive exam is recommended, unless your doctor advises otherwise.
A routine visit to a vision care network provider for eyeglasses likely will not include a dilated exam. Dilation enables a clear view of important tissues at the back of the eye, such as the retina, macula, and optic nerve and is key to early diagnosis of sight-robbing eye diseases like age-related macular degeneration, diabetic retinopathy, and glaucoma.