Today's health care environment has become more complicated and challenging to understand. We hope to clarify many misconceptions about third party care and your vision with the information below.
What is the difference between a vision discount plan and medical insurance? One of the most challenging billing issues in an optometric office is whether to bill the vision or medical plan.
An optometrist is a medical doctor (just like your family doctor) and provides comprehensive, medical eye health exams. However, optometrists also provide healthy, routine vision exams for people without any eye disorders.
In most cases, vision discount plans provide a wellness benefit and generally cover routine care such as a healthy eye and vision exam and include glasses or contact lenses. In some cases there may be a co-pay for each patient. The co-pay must be paid at the time of service. Each specific vision discount plan contributes to eyewear or contact lens purchases at different levels. The vision discount plan is not an entitlement plan and patients are free to choose any frame, lens or contact lens option recommended by their doctor.
Check with your plan to see if your benefits cover you once every year or once every two years. Eyeglass frames, lenses and contact lenses can usually be purchased at a discount, but not every plan has this benefit.
What do vision discount plans NOT cover?
Vision discount plans do not cover any part of an eye health exam considered “medical”. Medical insurance generally covers only eye care related to a medical condition. For example, if you need an eye exam because of eye strain, lazy eye, dry eyes, vision loss, floaters, cataracts, allergies, infections, complications from diabetes or high blood pressure, then your medical insurance will be billed for these services. You don’t need a vision discount plan for this coverage, but you may be able to use your medical insurance to cover your eye health examination and then use your vision discount plan to cover your vision assessment and glasses or contact lenses.
We will bill your insurance if we are participating providers and your insurance information is presented at time of service. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services.
Our practice fully participates in the Medicare program. We accept assignment of benefits on behalf of each eligible patient. The eye health examination is a fully covered service under the Medicare program. However, as mandated by Federal law, the refraction part of the vision section of your exam is a non-covered service. Each Medicare patient will be charged a separate fee for the refraction. This charge must be paid for at the time of service. Unless immediately following cataract surgery, there is no eyewear benefit under the Medicare program. The purchase of frames, lenses and lens options is the responsibility of each Medicare patient.
Hopefully, this information will give you a better understanding of your insurance benefit. Our billing specialists are available to answer any questions. Due to the large number of different vision discount plan and medical insurance programs, it is impossible to know the specific details and reimbursement policies of each. If our doctors do not participate in your insurance plan, we will be happy to provide you all the necessary forms and documentation for you to submit to the carrier for reimbursement.