Frustrations with Insurance & Eye Care

Posted on December 04, 2017

Frustrations with Insurance & Eye Care

By:  Jeffrey Colburn, MD

In this post I wanted to tackle a practical topic that often causes frustrations for both you and your eye doctor.  When you, or in our case your child, is getting an eye exam there could be confusion about what insurance covers the exam. 

For starters, it is important to understand the difference between a “routine” eye exam and a “medical” eye exam.  A routine eye exam occurs when you see the eye doctor for just a check-up when you have no problems.  Whether you should do so and how often you should do so depends on the age of the patient and who you ask, which is a separate question I won’t address here.  If your vision is normal with either glasses and/or contact lenses in place than that is also consider routine eye care. 

A medical eye exam occurs when you are being evaluated or treated for a structural or functional problem of the eye or brain.  Most of the time this means the problem can’t be corrected with glasses or contacts alone.  An exception to this might be refractive amblyopia, which is a medical problem that can be corrected with glasses with or without additional treatment needed.  An exam may also qualify as a medical eye exam if you have a systemic medical condition or are taking certain medications which may affect the eyes or vision and needs monitoring.

 “Vision Insurance” and “Medical Insurance”.  Vision insurance is not really insurance at all despite its name.  You may hear it called more appropriately a “Vision Plan” as it is a contract for service that entitles you to an eye exam on a periodic basis (usually every 1-2 years) and some dollar amount towards glasses and/or contacts if needed.  The plan than pays the doctor a typically low dollar amount flat rate for the eye exam.  So if you are just having a check of your eyes to make sure everything is okay when you are not having any problems, or if you just have a need for glasses or contacts to correct your vision, this may work out well for you.  The vision plan is not insurance because it does not insure you against the occurrence of any medical eye issues with any associated testing or treatment necessary.  They may lead consumers to believe that they cover all eye issues routine or not, but that is not the case.  The vision plan certainly would be happy if the eye doctor took care of complicated medical eye issues for their low flat rate payment but the reality is that they don’t cover the cost.  Therefore, your eye doctor may bill your medical insurance for the visit for the medical eye issues addressed or may split up the routine and medical portions of the eye care into separate visits.  Medical insurance will not cover your eye exam if there are no medical issues and in that case your routine vision plan will get billed or you will get billed directly if you do not have such a plan.  Medical insurances also do not cover an eye glass check (refraction) or glasses, with the exception of one pair of glasses after an adult has cataract surgery.

Bottom line is, you need to be aware of which vision and medical insurances you have and what they cover.  For vision plans, you need to be aware of whether you get a routine eye exam covered per calendar year or if you have to wait for one year plus a day from your last eye exam.  Some patients get turned away and re-scheduled if they come back in to the clinic before their routine insurance covers them again or may get billed directly instead.  Currently, our Washington state Medicaid pediatric patients have both routine and medical eye coverage, but you still have to be aware of how often your plan allows you to come back in for a “routine” visit.