Interested in learning more about the difference between medical and vision insurance and which will be used for your eye exam?

Vision Insurance

It is important that you understand that your Vision Plan (VSP, HMSA Vision) covers ROUTINE well-eye exams only (nearsightedness, farsightedness, and normal astigmatism) which includes the refraction to determine your eyeglass prescription. Some plans provide a limited contact lens evaluation benefit while other plans do not provide any contact lens evaluation benefit. As part of your routine well-eye exam, our doctors examine your eyes for many conditions and diseases including glaucoma, dry eyes, cataracts, retinal holes or tears, diabetic and hypertensive eye diseases, just to name a few.

If your routine well-eye exam reveals a medical condition or disease related to your eye that requires specific counseling, documentation, follow-up care, regular monitoring or referral to a surgeon, or if the exam is related to a pre-existing medical condition such as cataracts, glaucoma, diabetes, dry eyes, etc., then your visit is NOT COVERED by your Vision Plan. For instance, if you come in for a routine well-eye exam simply because you are having difficulty seeing with your current glasses, but it is found that your reduced visual acuity is due to developing cataracts, then your exam would have to be billed to your medical insurance. Unfortunately, the doctor cannot tell if medical eye conditions exist before you are thoroughly examined.

Medical Insurance

The good news is that your Medical Insurance can be used when an eye-related medical problem such as eye injuries, pink eye, double vision, headaches, cataracts, dry eyes, complications from diabetes or high blood pressure (among many others) is found during the course of the eye examination. You do not need a vision benefits rider on your medical insurance to be covered for a medical eye condition, as it is covered in a similar fashion to the way that a visit to any medical specialist is covered. In these cases, your Medical Insurance will be billed for the eye exam even though a Vision Plan may also be in effect because you are being treated for a medical condition.

Your Medical Insurance co-pays and deductibles prevail and must be paid at the time of your exam. If a referral is required by your insurance plan in order to see a specialist, then you are responsible to obtain it. Believe it or not, a comprehensive examination that is medical in nature does not include the refraction. Nearsightedness, farsightedness, astigmatism, and the need for reading glasses are not considered a medical diagnosis.  Medical insurance plans will deny this portion of the examination. If you have both medical and vision insurance plans, our office will coordinate the benefits to minimize your out-of-pocket costs. You can still use your Vision Plan material benefits towards the purchase of eyeglass frames, lenses or contact lenses based on your specific plan’s allowances

At times it can seem like a complicated process, but these are the rules set by your insurance company. We would be happy to answer any questions that you may have about your insurance coverage.

If you would like to save time at your appointment, and so we can have your most accurate information, please complete your health history and demographic information via the patient portal