Insurance benefits these days have become quite confusing. We are finding that a lot of patients are either unaware and/or misinformed regarding their medical and vision benefits. Vision insurance and the difference between vision and medical benefits are something that is confusing for a lot of our patients.
When making an appointment for a comprehensive exam at the office, we need to know which vision insurance carrier you have so we can make sure you have benefits prior to the exam. The plans we are in-network providers for include Vision Service Plan (VSP), Eyemed, and Medical Eye Services (MES). These are stand-alone plans that have exam coverage and material benefits (towards either glasses or contact lenses). These plans vary greatly in material benefits and coverage terms, but all have exam benefits. Some of these vision plans are associated with your medical insurance, but are usually administrated differently. For example, Cigna health insurance is associated with VSP and Aetna coordinates some of their vision plans through Eyemed. Even though they are related, your medical insurance and vision coverage are usually separate entities.
That being said, sometimes medical plans do have routine vision coverage. The problem we have found with plans such as Anthem Blue Cross and United Health Care is that patients are confused as to whether their benefits apply towards medical eye visits or routine care. The main difference is that for a medical benefit, a medical diagnosis must apply. Such things as conjunctivitis, cataracts, allergies, glaucoma, diabetes, dry eyes, etc. are medical diagnoses. Myopia and astigmatism are not considered medical and therefore would not be covered. For instance, a patient who comes to the office with only a vision issue and does not have an ocular medical condition, medical coverage alone cannot be used. So when a patient calls the office and tries to use their medical insurance for a routine exam, we have to assume there will not be a medical diagnosis. Therefore, we need to know what coverage there is for routine vision and materials. If a patient is calling to schedule an office visit for a red eye, infection, allergies, etc. the opposite is true. The medical insurance is now primary because the routine vision plan will not pay for a medical eye visit.
Now that we all understand the difference between medical and vision insurance, it is important to understand what benefits you have before calling the office to schedule an exam or office visit. If you are not sure, the human resources department through your employer should be able to help you navigate through the chaos that is insurance. If you don’t have any vision insurance through your employer or are self-employed, VSP now has individual plans available for purchase. These plans have exam coverage along with material benefits. For patients that need contacts annually or need glasses, the individual plans have basic frame and lens coverage, and then discount any upgrades to the frames and lenses. For patients who don’t need any materials, it probably doesn’t pay to purchase these plans, but for those who need glasses and/or contacts, your out-of-pocket costs will be much less than paying privately.