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Medical vs Vision Insurance Explained

What is Vision Insurance, and how is it different from Medical Insurance?

A Vision insurance policy is different from your health insurance policy. Regular medical health insurance protects you from unexpected costs from eye injury or disease. In contrast, Vision insurance provides an added wellness benefit for healthy eye exams, which includes routine eye care, prescription eyewear and contact lenses, and other vision services at a reduced cost. Some examples of Vision insurance include VSP, EyeMed, EyeQuest, Superior Vision Network and Davis Med.

What does Vision insurance cover?

Most Vision insurance plans include the following benefits:
  • Annual vision exams
  • Eyeglass frames
  • Eyeglass lenses
  • Contact lenses

Check with your plan to see if your benefits cover you once every year or once every two years. Eyeglass frames and lenses and contact lenses can usually be purchased at a discount, but not every plan has this benefit.

Prior to your visit, please make sure you are familiar with the optical benefits offered by your vision insurance. During your appointment, you will be presented with some options for purchasing eyeglass frames/hardware. Payment will be due in full at the time of your order, which means any costs above your insurance coverage will be your responsibility. If you are unsure of your specific coverage for eyeglasses and other optical benefits, we encourage you to call your insurance company before your visit with Confluence Health.

What does my Vision insurance NOT cover? Vision plans do not cover any part of an eye exam considered “medical”. For example, Vision insurance will not cover vision loss, floaters, dry eyes, allergies, infections, eye disease, or eye exams for complication from diabetes. If you need medication, the doctor will not be able to give you a prescription if you are using a Vision insurance.

Additionally, some Vision insurance plans do not cover contact lens fittings (for first time wearers or established wearers that need to switch to a new brand) or yearly contact lens evaluations.

When do I use my medical insurance at the eye doctor’s office? Your medical insurance is usually used if you have an eye problem or eye disease or if any medical condition is present that causes eye problems. Some common conditions for which we can bill your medical insurance include:
  • Patients with vision loss
  • Patients with glaucoma
  • Floaters
  • Dry eyes
  • Allergies
  • Infections
  • Monitoring cataract development
  • Examination of patients diagnosed with diabetes
  • Examination of patients using medications with potential eye side effects, such as steroid medications, arthritis medications, etc.
  • Patients that are at high risk for glaucoma development
  • Patients with macular degeneration

When you call to make your next appointment with the eye doctor, make sure to explain the purpose of your visit so that we bill the appropriate insurance. Additionally, please always bring your insurance card(s) with you to every appointment.

What is a Refraction? A refraction is when your eyes are checked to see if you need a new eyeglass or contact lens prescription. For the most part, health insurance won’t cover the fee for the refraction (estimated cost $55.00), which is a procedure that is separate from your eye health exam. Your vision insurance will cover the refraction, but not the exam if you are having a medical problem.

Will Medicare cover my eye exam for new glasses or contact lenses? Unfortunately, no. Medicare does not cover routine eye exams where your glasses or contact lens prescription is checked. Medicare will only pay for eye exams relating to medical complaints.

Can I use my vision insurance and my medical insurance for a joint exam on the same day? No. By law, we cannot bill two different types of insurance on one day. There are two alternatives. First, we can always schedule your medical and vision visits on separate days, allowing us to bill your insurances on different days. You may have to go through some repetitive parts of the exam on those days because by law there are certain things the eye doctor must document at every visit.

Why is insurance so complicated? Good question! We don’t make the rules, we just follow them. You can call the phone number on the back of your insurance card or look up your insurance policy details online. Ultimately it is your responsibility to understand the policies of your insurance companies, both medical and vision. Please call us if you have any remaining questions.

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