Health insurance policies pay for many types of medical care but they do not always cover eye exams and prescription lenses.
By law, health insurance policies must cover certain medical procedures but the law does allow insurance companies to exclude certain services. This means some insurance policies do not pay for certain tests, procedures or treatments that are not essential for the policyholder’s health. Many insurance companies view eye exams as a value added benefit that may improve the quality of life but not as an essential service, so they do not pay for eye exams or corrective lenses.
There are exceptions to this rule, however, as it depends on the age of the patient and the health problems that patient might have. Patients who need more coverage than their current health insurance provides may be able to supplement their coverage with a vision insurance policy available in the area.
DOES HEALTH INSURANCE COVER EYE EXAMS?
Coverage depends largely on the policy – some insurance policies consider an eye exam as a form of preventative care or maintenance in cases where the patient is not experiencing any specific eye complaints, while others cover yearly eye exam, glasses or even contact lenses when purchased from an approved distributor. Policyholders should review their policy’s schedule of benefits to learn if their insurance plan provides coverage for regular eye exams.
INSURANCE MAY COVER EYE EXAMS FOR SOME CONDITIONS
Some insurance companies will pay for vision exams or preventative when a policyholder experiences certain health problems, even if the policy does not expressly provide coverage. Medical insurance may pay for the cost of an exam for dry eye symptoms, eye injuries and visual disturbances, as these temporary or chronic eye conditions may indicate a more serious health problem.
Patients who suffer these conditions should check their schedule of benefits or contact their insurance companies for more information if the policy is unclear about coverage for these conditions.
PEDIATRIC EYE VISION INSURANCE
Pediatric eye vision insurance is required for all children as an Essential Health Benefit (EHB) offered by the Affordable Care Act. This means all Qualified Health Plans (QHPs) sold on the Marketplace must offer coverage for basic eye care services for children aged 18 or younger, according to HealthCare.gov. As such, insurance plans must cover annual eye exams. Some states interpret the law as meaning that insurance companies must also cover eyeglass lenses and frames, and contact lenses instead of glasses for children.
EYE CARE INSURANCE FOR ADULTS
The Affordable Care Act does not require that insurance companies provide coverage for adult eye exams, and does not offer tax credits for adults who do pay for eye exams. Adults can purchase standalone insurance plans to cover eye exams. These insurance plans typically cover exams, eyewear and discounts on surgical correction of vision.
Purchasing a standalone policy for eye care can save a consumer hundreds of dollars each year in eye exams, corrective lenses and therapeutic procedures to correct eye problems. The Marketplace associated with the Affordable Care Act does not offer standalone vision insurance.
WHAT TO EXPECT FROM VISION INSURANCE
There are two general types of vision insurance coverage: a vision benefits package and a discount vision plan. A vision benefits package offers free eye care services and eyewear within a specific dollar amount and requires an annual premium or membership fee along with a small co-payment for each service.
A discount vision plan typically offers eye care and eyewear at discounted rates. Vision plans usually cover annual eye exams, eyeglass frames, eyeglass lenses, eyeglass lens coatings and enhancements, contact lenses, and discounted rates for certain types of vision-correcting eye surgery, such as LASIK and PRK.
All plans may also include a deductible, which is a specific dollar amount that the policyholder must pay before insurance benefits kick in.
VISION INSURANCE CAN SAVE CONSUMERS MONEY
Consumers can save money on eye exams and eye care by purchasing vision insurance. AllAboutVision.com lists the costs of various eye care services with and without insurance. That site says that a consumer without insurance would pay about $154 for a comprehensive eye exam, whereas the typical consumer would only pay about $15 co-pay. A consumer without insurance would pay about $159 for eyeglass frames and another $86 for lenses, and someone with insurance would hand over only $9 for the frames and another $25 for the lenses.
The insurance company would also pay for other services, such as anti-reflective coatings and other lens enhancements, which a consumer without insurance would have to pay out of pocket.
Who pays for eye exams depends largely on whether the consumer has vision insurance, either through an employee health plan or as a standalone policy. Consumers should always talk with the dentist billing department to learn about coverage when scheduling an appointment for an eye exam.