Does My Insurance Cover an Annual Eye Exam?
Figuring out the specifics of your medical insurance can be tricky, especially your vision coverage. Depending on your individual policy, some routine annual eye exams can be covered, but unfortunately most are not.
Since vision coverage is an add-on to regular health insurance, it can be hard to understand what benefits are included and which ones have additional associated costs. To simplify this, insurance companies categorize your visits to the eye doctor into two groups: routine visits and medical visits.
These two types of visits are still considered to be full eye exams covering the same elements, and the type of eye doctor you see does not change. Either an optometrist or an ophthalmologist can perform a routine or medical eye exam and the price can range anywhere from $50 to over $250.
So, what is the difference between these exams and how does this difference determine the cost?
Understanding the Difference Between a Routine Exam and a Medical Exam
Routine Eye Exams
The main difference between these two categories is the reason for being seen, such as symptoms or complaints, and the results or diagnosis of the exam. That determines what your insurance will classify the exam as, and as a result, what the benefits will cover.
Typically, a routine eye exam ends with a diagnosis of a common vision condition like nearsightedness or astigmatism.
Depending on your health insurance policy, most routine eye exams will not be fully covered. However, some policies that contain separate vision plans provide some coverage for glasses and contact lenses and may also include discounts on customary fees from the doctor.
In other situations, some medical insurances have a separate “rider” policy to cover routine eye exams.
Unfortunately, even if some medical insurances like EyeMed or Humana do cover routine exams, they may put a limit on the number of exams they fully cover per year. Depending on the plan, they will pay all or part of the cost of your exam and give you a timeline of how often you are able to get a covered exam or eyewear allowance.
- Example: One routine eye exam will be covered every two years in addition to covering medical eye exams.
The Cost of a Routine Eye Exam
As stated earlier, the cost of a routine eye exam depends on the type of insurance you have. If you have a standard vision insurance policy, you’re only responsible for the co-pay, and the rest of your routine eye exam cost will be covered. A typical vision insurance co-pay ranges around $10-40 dollars depending on the type of coverage.
If you are without health insurance, or your health insurance does not cover vision care, then you’ll have to pay out of pocket for your eye exam. Depending on whether you visit an optometrist or an ophthalmologist — as well the practice you choose to visit — these basic routine eye exams can range anywhere from $50 to over $250.
Medical Eye Exams
A medical eye exam typically ends with a diagnosis of conditions like conjunctivitis, glaucoma, age-related macular degeneration or cataracts. These are more serious conditions that either require further medical attention and possibly surgery.
Depending on your health insurance policy, most will cover eye exams if you have or are suspected to have an eye health problem. Keep in mind that the co-pay for each type of exam may also vary between different policies.
If you are still unsure about what your insurance policy will cover, you can check the statement of benefits on your plan or call and ask your provider.
The Cost of a Medical Eye Exam
As mentioned above, if you have health insurance, you may only be responsible for the co-pay and the rest of your medical exam will be covered. These co-pays range around $10-40 dollars.
If you are for some reason without health insurance, we work closely with self-pay patients through the Care Credit program.
A Realistic Example
Let’s assume your employer provides both types of insurance: health insurance as well as a separate vision plan, and you have elected to have both options. Your old glasses are terribly outdated, the hinges keep breaking, or you need a new contact lens prescription because you’re almost out lenses, so you decide it’s time for an annual eye exam.
You make an appointment to get an eye exam and to purchase a new pair of glasses. Your benefits are authorized at your eye doctor’s office and you proceed with the examination. At the end of the exam, your doctor gives you your updated prescription but also notifies you that she found signs of a developing retinal detachment. She schedules you to come back within one week for further examination with an ophthalmologist.
Even though your doctor found signs of a retinal issue, this specific visit would be covered under your vision plan because of the original intent behind the visit. You came in simply for an eye exam and a new pair of glasses. However, because your eye doctor found early signs of an emerging eye condition, your medical insurance will cover the further testing and office visits related to this issue.
Depending on your coverage, it is possible that you could also use your medical insurance to cover your next annual examination, because it was determined that there are signs of a developing retinal issue.
Should I Visit an Optometrist or an Ophthalmologist?
Routine and medical visits are both full eye exams that cover the same elements and can be performed by either an optometrist or an ophthalmologist.
If a standard eye exam is needed, then visiting an optometrist will do the trick. They primarily perform vision exams, prescribe glasses or contact lenses, and can detect many eye conditions. Keep in mind that they are not medical doctors, and they may not be as familiar with all the health conditions that can affect the eyes as an ophthalmologist would. However, they can distinguish eye abnormalities and refer you to an ophthalmologist for further evaluation if necessary. Ophthalmologists are medical doctors who can diagnose and treat eye diseases, perform surgery, and practice medicine.
General Tips & Guidelines
Even though most eye care professionals are mindful of the different types of insurance plans, be sure to:
- Review your individual plan with your insurance provider or benefits administrator so you get the correct information. Take advantage of asking questions during your enrollment period or at your employer’s benefit fair, if offered.
- Be aware of all the possible deductibles and co-pay options your plan offers.
It is in your best interest to be fully aware of your benefits and co-pays so you know what to expect when it comes to different examinations and financing options.
If you have any questions regarding the vision and health insurance plans we accept and what procedures are covered, a staff member at Eye Centers of Florida will be happy to help you find the answers you need. Please call 888.EYE.APPT (239-320-7342).