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Medical vs Vision Insurance?

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Q:  When I called to make my next eye exam appointment, they asked for my medical insurance as well as my vision plan……why?

A:  For reasons unknown to me, only eye exams offer the physician a choice of both.   And perhaps more importantly to patients, virtually all vision plans actually require your eye doctor to bill medical insurance for any exam where a medical diagnosis is found as the primary cause or concern.

We see this is our clinic also.   A patient calls to make an appointment for new glasses or contact lenses, because they have noticed their vision is not as sharp as they need, or used to be.  If this symptom of vision change is ONLY caused by a “refractive” change, we can use your vision plan for coverage.  Refractive means your vision correction has changed.

But very often, the symptom of vision problem may be caused by a medical diagnosis.   Common problems we see might be dry eye disease, diabetes in the eye, early cataracts, or even swelling the retina.   None of these cause much, if any, discomfort but do cause changes in vision.  These medical diagnoses are the sort of thing that vision plans do not cover.  Only your medical, or “health” insurance covers examinations for those disorders.

This complicates things for us also, because medical insurance generally carries a higher co-pay requirement than vision plans.   This means they require the patient to pay more upfront.  And most medical insurance does not cover the vision testing….that refractive part.   This means the patient is required to pay for the refraction part of the eye exam.   This has been true for Medicare for many years, but may be new for commercial insurance patients.  Lastly, most vision plans will not allow your eye doctor to bill only your vision test to them!

So, sorry if this is a bit complicated, but these are the rules that every eye doctor must follow.  Of course, this is way too much to try to explain over the phone.   So you are not alone, as many people encounter this vision versus medical coverage issue.  You, as the patient, cannot be expected to know ahead of time what is actually causing your symptoms.  And you could not possibly know if another silent disease is starting a problem inside your eyes.

The bottom line is to give the office both coverages and when you are in the office, just ask the staff or better, the eye doctor, if the exam is considered more medical or vision?  The good news would be that while vision plans are very strict in offering coverages only every twelve months, medical insurance has no such restriction.   If your eye doctor needs to see you more often for a medical eye concern, those visits should all be covered.

This unique double coverage for eye exams has it good and bad points.  As we unfortunately joke, it seems that insurance companies are running the world!  Patients encounter this commonly with prescription medication prices, and now with eye exams too.