Insurance and how it works
Now more than ever as Obamacare shifts the cost to the policy holder it is important that patients understand how insurance works. Health insurance is not healthcare. It is the mechanism that covers a portion of the cost of healthcare. All insurance plans are different and what the employer pays determines what benefits will be covered. The vast majority of plans have deductibles, copays and or coinsurance. The deductible is the amount that the policy holder must pay before any benefits will considered for payment. Copays are the amount you pay for a service or office visit. It is a specific amount. Coinsurance is the amount where the policy holder will pay a percentage of the covered cost of a test, procedure, service or medication. Your policy may have one or all of the cost sharing out of pocket expenses.
Eye examinations are slightly more complicated. An eye exam consist of 2 portions. A Refraction which is the portion that just measures to see if you require glasses in order to see more clearly. This is the portion that a patients VISION plan pays for ( Davis, Eyemed, VSP, Spectera, etc). The other portion is the medical testing that is done to evaluate the health of your eye to rule out any other reason that is causing you to have blurred vision or eye symptoms like dry eye, floaters, itching, redness, pain etc. Here is the confusion. If you have any of these symptoms or complaints, family history of eye disease, medical conditions such as Diabetes or Hypertension or existing eye diseases then this portion is billed to your medical plan and your visit is no longer just a Vision exam. It goes even further, if the patient complains of blurred vision and the cause is determined to be from an eye disease like Cataracts, Macula degeneration then this too becomes a medical visit and billed to the medical carrier. If a refraction is also done at the same time, then this portion is billed to the VISION plan.
Our office does a comprehensive evaluation that incorporates both portions of the eye examination. Additional testing may be done if there is a sign, symptom, complaint or family history or an eye problem that is not solely attributed to a sight or vision problem. Our eyes are way more complicated than any organ in the body and as a result require more skill and expertise in diagnosing and managing their overall health. The last thing we want is to miss something that could lead to blindness or vision impairment. We trust you agree with this approach.
Contact lens exam require even more scrutiny because a medical device is being placed on the eye that can alter its structure, function and overall health. With this in mind additional tests are imperative to give us both a baseline and determination if the eye is structurally sound to wear a contact lens. Vision plans do not cover the cost of the additional tests. These are billed to your medical plan. The contact lens exam includes the determination of the initial pair of contact lenses and all the follow-up visits for a period of 90 days and any additional lenses needed.
If you have questions we urge you to contact your insurance company since they can explain things because they have access to all your benefits and how much your employer has chosen to purchase. We do not have access to this information. They only provide us with basic information about your plan.
An HMO is a group of healthcare providers — doctors, laboratories, hospitals and the like — employed to provide health care to plan members at discounted rates. Usually, plan members are required to access health care (including vision care) only from HMO providers.
A PPO is a network of healthcare providers organized to provide healthcare services to health plan members at a fixed rate below retail prices. Plan members may opt to access out-of-network providers, but usually at a greater cost.