What is the difference between medical insurance and vision insurance and why do I need both?

               Medical (or health) insurance is the regular insurance you use when going to the doctor. It covers you when you are sick, need surgery or a procedure and some preventative care such as your yearly checkup.

               Vision insurance covers “routine” eyecare. This refers to your yearly eye exam for glasses or contacts when no other medical diagnosis is present. The doctor will check the health of your eyes at this exam, but if your eyes are healthy it is considered a routine visit. When there is another diagnosis or condition present which would affect the health of your eyes, it is considered a medical visit. Some examples of these conditions are diabetes, glaucoma or cataracts. Sometimes if you are taking certain medications, our doctors will need to monitor your eyes for negative side effects and report back to your primary care provider. These visits are also considered medical and can be filed with your health insurance.

I don’t have any medical conditions which affect my eyes- why do you need my medical insurance information?

Sometimes you may visit us for a reason other than your yearly eye exam. You may injure your eye or have an infection or be experiencing dry or allergic eyes. These visits are medical in nature and your medical insurance will likely help cover them. We put your medical insurance information in our system so if you ever need to use it for the visit, it’s ready to go.

FYI: some tests will not be covered by medical or vision insurance at all. Things such as retinal imaging, contact lens evaluations or refractions may require out of pocket copays. We will always inform you when that is the case.

How does insurance work regarding contact lenses or eyeglasses?

Medical insurance will not pay for glasses or contact lenses except in extremely rare cases.

Routine vision insurance will help you to pay for part or all of these items depending on your plan. Most plans will allow one pair of glasses OR contact lenses within a one year period. Some plans will provide coverage for glasses or contacts just every other year. Some plans will provide spectacle lenses or contact lens coverage every year but frames only every other year. We are happy to look up your coverage and explain the details to you. There will likely be copays on your glasses or contacts and any options added to glasses such as progressive lenses, anti-reflective coatings or transitions will have charges that are specified by your plan. Our staff is very well educated in all the various plans and will strive to help you maximize your available benefits. We will also file all in network benefits on your behalf.

My plan covers medically necessary contact lenses. I need my contacts to see- why aren’t they covered under this?

Some plans will cover contacts which are necessary medically and is a great benefit for those who qualify. However, the requirements for medically necessary coverage are very strict and specific and most will not qualify. The truth is, qualifying is not necessarily a “good” thing. Medically necessary contact lenses are non-elective contact lenses prescribed when certain medical conditions hinder vision correction through regular eyeglasses and contact lenses. With some medical conditions, patients are unable to achieve a specified level of visual acuity or performance through regular eyeglasses.

Such medical conditions include:

• Aphakia – the removal or absence of the lens of the eye(s) due to surgery, injury, or abnormality.
• Anisometrophia – a refractive condition where the eyes have unequal focus or optical power
• Keratoconus – an eye disease that causes structural damage to the eye’s cornea, changing from the normal, round shape to a bulging, cone shape.

I have cataracts and need surgery. Which insurance will help pay for that?

Cataract surgery will fall under your medical insurance benefits. There is usually some out of pocket cost associated with this procedure as well.

What about Lasik?

Lasik surgery is considered cosmetic and will not likely be covered. However, some vision insurance plans offer a pre-arranged discounted fee with some providers.

Can I use my Health Savings Account (HSA) or my Flexible Spending Account (FSA) to pay for my eyecare?

Absolutely! All eye exams – routine and medical qualify for HSA and FSA and you can also use those cards to pay for your glasses and contact lenses. We are happy to provide you with detailed receipts to turn in as well.

Hopefully, this clears up some of the questions surrounding insurance coverage and eyecare. And, our staff is always available to help with your concerns and happy to answer any additional questions you may have!