Vision vs Medical Insurance

Optometry is a unique profession because our patients can utilize two types of insurance in our offices. Many of our patients are fortunate to have vision insurance AND medical (health) insurance. The question often comes up “who covers what?” in our office. Let’s start with vision insurance. Sometimes referred to as an “eyeglass plan”, vision insurance is designed to save the subscriber money on routine eye exams, glasses and contacts. All vision insurance plans have morphed over the last 10 years to become more of a discount plan rather than “insurance”. By definition, insurance is designed to reduce financial risk involved with expensive, unplanned and potentially catastrophic loss. Importantly, there is nothing unpredictable or catastrophic about routine eye care. Most patients spend less than $350 per year on eye care. Many perceive routine eye care and eye wear as much more expensive than is reality. Especially those who have always utilized a vision plan, just don’t realize the reasonable and predictable cost of eye care. According to a recent study, most patients with vision insurance only utilize the plan once every 1.9 years. Interestingly, most vision plans cost patients $120-150 per year. The average benefit allowed by vision plans is $150-200 and will only cover glasses or contacts, not both. Simple math shows the limitations of a vision plan.

Medical (health) insurance plans are utilized in our office when a patient has a medical diagnosis involving the eyes. Patients with dry eyes, cataracts, glaucoma, macular degeneration, eye infections or injuries all utilize their health insurance to offset the cost of care. An eye exam on a patient with these, or countless other related conditions, is different and often more complex than routine care. In most circumstances, ancillary testing, coordination of care, and advanced procedures are involved. A medical diagnosis, including many systemic conditions (like diabetes, hypertension, arthritis) require that the exam and related procedures are billed to the health insurance plan. Vision plans will not cover an eye health exam involving a medical diagnosis.

For those fortunate enough to have vision and health insurance, both can be used in our office for the same visit. Specifically, your health insurance may cover the exam portion while glasses or contact lenses are covered (in part) by the vision plan. In addition, our office can coordinate your benefits to maximize your out of pocket savings on eye care and eye wear. In the case of medicare and other health insurance, a vision plan may be included with the plan. The vision plan is administrated by a separate entity and not the health plan. In many of these cases, the vision plan is mistakenly thought of as full or primary coverage. This has led to some confusion for our patients, but our staff is happy to help explain how best to maximize your coverage with both insurances.

As always, we look forward to providing you with the very best eye care available. Our doctors and staff are constantly reviewing available insurance packages so we know how best to utilize your insurance for your maximum benefit. We appreciate your trust and patronage.

J. Gregory Ford, OD
Senior Partner
West Michigan Eyecare Associates