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FAQs of Vision Insurance Plans

How and Where Does One Obtain Vision Insurance?

Individuals can buy a vision benefit plan. Vision insurance plans may be available through your place of employment, school district or through social plans like Medicare or Medicaid.

Indemnity health insurance is traditional insurance, which allows policyholders to access medical providers of their choice. Vision insurance is often a value-added benefit included in indemnity health insurance plans, health maintenance organization (HMO) plans and plans offered by preferred provider organizations (PPOs).

An HMO health plan requires its members to access health care only from HMO providers. HMOs provide health care services to plan members at discounted rates. HMOs include a range of health care professionals – doctors, laboratories and hospitals.

A PPO is a network of health care professionals who provide health care services to membership at discounted rates. Plan members may use out-of-network providers, but they usually will pay more for the services rendered.

What Types of Vision Insurance Plans Are Available?

Vision insurance comes in two forms, a discount vision plan or a vision benefits package.

Discount Vision Plan – Eye care at fixed discounted rates after an annual premium or membership fee and a deductible are paid.

Vision Benefits Package – Usually, a vision benefits package requires an annual premium or membership fee, a yearly deductible for each enrolled member and a co-pay each time a member accesses a service.

Discount vision plans and vision benefits packages are custom-designed to meet the different requirements of a wide range of customers, such as unions, big, mid- size and small companies and school districts.

What is included in vision insurance?

Standard Vision insurance usually includes the following services and products:

  • LASIK and PRK vision correction at discounted rates
  • Annual eye examinations
  • Contact lenses
  • Eyeglass frames
  • Eyeglass lenses

Usually, services acquired from network providers are more affordable than services from out-of-network providers.

Are there payment options?

If group vision insurance is available from your employer, you pay for it through payroll deductions or flexible spending accounts.

A flexible spending account, sometimes referred to as a cafeteria plan, allows an employee to use pre-tax dollars to purchase selected health benefits such as vision insurance. This plan saves your money because you receive the full benefit of income that has been set aside for health costs, making it not subject to or reduced by taxation.

If you are self – employed or if your employer does not offer vision insurance then you can expect to be billed monthly or annually.

Will my exam be covered by insurance?

Most eye exams, whether for a specific eye problem or for general vision care, will be covered at least in part by your primary medical insurance. As with any medical visit, your usual copays and deductibles will apply. Some services, including refraction and contact lens exams, may not be covered.

For insurance purposes, eye examinations are classified as either “Medical” or “Routine.” Your medical history, current symptoms, and examination findings will determine how your visit is coded.

What is a “Medical” eye exam?

Your visit will be coded as a medical exam if any of the following apply:

• You have any symptoms related to the health of the eyes, such as headaches, eye pain, itching, tearing, redness, dry eye, sudden vision changes, double vision, light sensitivity, floaters, etc.

• You have a known medical eye condition, such as cataracts, glaucoma or macular degeneration or you have a family history of glaucoma

• You have a history of diabetes, high blood pressure, or certain other medical diseases

• You are diagnosed with a medical eye condition during your exam

During a medical eye examination, the doctor will evaluate the reason for your symptoms and determine if any treatment or additional testing is required.

What is a “Routine” eye exam and will my insurance cover it?

If none of the above apply to you, this constitutes a routine “well-vision” exam. During a routine exam, your eyes will be examined for any needed visual correction (glasses, etc.) and screened for potential indicators of eye disease.

Please be aware that many insurance plans do not cover “routine” eye exams and will only cover your exam if you have medical symptoms related to the eyes or you are diagnosed with a medical eye condition.

Some insurance plans will cover a routine exam once every 1 or 2 years, depending on the policy.

You must notify our staff in advance of your exam if your plan will cover a “routine” eye exam. If you are unsure, we recommend that you check with your insurance company prior to your exam. Once we submit a claim, it cannot be changed from medical to routine or vice versa.

Refraction: What is it and does my insurance cover it?

Refraction is the diagnostic procedure used to determine your best-corrected vision. This can be achieved at all ages using different techniques, but usually involves looking through a device with adjustable lenses while the doctor has you read letters on an eye chart. Refraction must be performed in order for the doctor to prescribe glasses. For some medical conditions and for most children who have been referred after a failed vision screen, refraction is needed even if glasses are not prescribed. Unfortunately, the majority of insurance companies (including Medicare) do not cover this essential procedure. If your insurance does not cover refraction, you will be billed accordingly. The current fee for refraction is $55 (subject to change) and is due on the day of service.

Does Eyes on Elm accept Vision Plans for eye exams?

Yes we do for “routine” eye examinations only. If you have any medical symptoms related to the eyes, or if the doctor diagnoses any medical condition during your exam, your claim must be processed through your regular medical insurance.

Will insurance cover my contact lens examination?

Medical insurance plans do not consider contact lenses medically necessary and will not typically cover contact lens fittings or annual contact lens examinations. Vision insurance plans typically have a separate co-pay for a contact lens fitting and exam. The co-pay typically ranges from $40-$135 depending on your plan and the complexity of the visit.

What if I don’t have any insurance?

Our prices are the best in town because we believe everyone should be able to afford a comprehensive eye exam.

Please see the “exam pricing” section of our website.

Can I have a contact lens prescription without doing a full eye exam?

We can most definitely do a contacts lens fitting only as long as the patient has had an eye exam within the last 6 months.

We kindly ask you to contact the office where the last eye exam was performed and request a copy of the records & prescription be faxed to us at 203-842-5996. If we do not receive this before the scheduled visit, our optometrist will need to do a full eye exam before being able to do the contact lens fitting.

Our optometrist will review the records from the last eye exam and base the contact lens prescription off of that. If the vision is not clear, our doctor will need to do a refraction to update the prescription.