Understanding Your Vision Benefits

Let’s face it, insurance can be confusing. This is particularly true when an individual has both medical and vision coverage. Understanding your insurance PRIOR to any service can help you avoid confusion and frustration.
VISION INSURANCE is one of the most misunderstood benefits of all health-related coverage. Some insurance companies do a better job of educating their clients than others. At times insurance companies’ “customer service” departments overstate benefits (and minimize or even ignore specific limits and restrictions) that can create an adversarial relationship between the patient and the doctor’s office. We would like to avoid these misconceptions, and we hope that the following will help you better understand how vision coverage works.
Medical vs. Vision
Medical insurance DOES NOT cover vision related issues such as routine exams, glasses, and contact lenses. Many people with medical insurance have a separate rider policy to cover routine eye exams.  Most vision plans to do not cover ANY medical testing, diagnosis, consultation or treatment. Vision  insurance  covers  ONLY  routine  eye  exams  for  purchasing  glasses  or  fitting  and  purchasing  contact lenses. Regardless of your vision insurance, most plans do not cover 100% of expenses, and thus you should expect some out-of-pocket costs. There may be co-pays, deductibles or a percentage of costs that you will pay out-of-pocket as required by your insurance policy. As with most doctors, at Children’s Eye Care the patient’s portion must be paid before materials (glasses or contacts lens) can be ordered. And all co-pays are due at the time services are rendered.
MEDICAL concerns (Glaucoma, Dry Eyes, Macular Degeneration, Red-Eyes, Floaters, Allergic Conjunctivitis) take priority and as such will be treated first or concurrently with a vision problem. Sometimes a medical condition has to be treated and corrected before vision can be accurately evaluated. Medical insurance companies usually separate the components of an eye exam, one being the comprehensive exam and the other being the refraction. (The refraction determines the prescription for eyeglasses and contacts.) Typically, VISION insurance policies usually cover both the ROUTINE EXAM and REFRACTION, while MEDICAL policies cover the EXAM only. You are responsible for the cost of the refraction if your insurance is medical only.  If the presence of disease is detected that require additional testing, the doctor will provide you information regarding the condition and the testing required.  Depending on your insurance policy, deductibles and coverage services rendered may have some additional out-of-pocket costs that cannot be determined until your insurance company has been billed and provides an eligibility of benefits (EOB).  Regardless, you will be responsible for any deductibles our out-of-pocket costs. 

In Summary
Although our staff members are very knowledgeable about insurance plans, remember that it is not the doctor’s or staff’s responsibility to know the details of your individual plan. It is to your benefit to be aware of possible deductibles and co-pays that are part of your plan. Your insurance plan may cover routine vision care, but if your deductible has not yet been met, you will still have to pay for the service    until your deductible is met. Your insurance is a contract between you, your employer and the insurance company; not with the doctor. We encourage you to speak with your insurance company PRIOR to your appointment about your plans specific details. Then, as always, feel free to ask us questions about how they will apply to your upcoming visit. We will do everything we can to help you better understand your policy, but the more knowledge you have about how it works ahead of time, the less frustrating it will be for you at the time of the exam.