Insurance can be a very confusing thing…even for those of us who have to deal with it on a daily basis. Defining what your coverage is, when it comes to vision benefits, can be a very loaded question. Moreover, knowing which insurance company you have, often tells us relatively little about what your coverage will entail.

First Things First

Probably the most confusing thing for most patients is understanding that your medical insurance is not necessarily your vision insurance. Most eye care professionals will take both medical and vision plans, but medical plans will only cover the examination–and ONLY if there is a medical diagnosis! So, I’m sure your next question is, “what is a medical diagnosis anyway?”

In order for an eye doctor to bill any kind of visit to your insurance, we need to use diagnosis codes, which define the reason for your visit. A prescription for corrective eyewear is not considered medical, believe it or not. A medical diagnosis, generally means a visit which requires a pharmaceutical treatment (but not always!). So, we can only bill your medical insurance if you’re seeing us for a foreign body in the eye, an eye infection, glaucoma, etc.

If you’re coming to us for contact lenses or glasses, then only a vision insurance can be used.

So What is a Vision Insurance (Or Alphabet Soup)

                               

Typically, your medical insurance will contract with a secondary insurance which specializes in vision coverages. For example, if you have Aetna for your medical, then you almost definitely have EyeMed for your vision insurance. A vision insurance is about covering your routine annual eye exams, and any corrective eyewear you may need.

Amongst the major vision insurance companies, each company can have thousands of variations on the coverage available, all based on what your employer has negotiated as your coverage level.

How Vision Insurance Works

There is actually quite a wide variation on how vision insurance plans cover your materials. However, there are some overarching methods which apply to the vast majority of plans…

The Breakdown

Most plans have your coverage broken down by specific frame and lens components. For example, you may have $120 available towards a frame. And typically, you would pay only 80% of the overage. So, in this example, if you chose a frame that costs $250, we would subtract $120, leaving $130, and then we would subtract 20%, leaving a patient balance of $104.

The lens coverage usually has specific dollar amounts we are required to charge for each lens “option.” So, following through the example, let’s assume you need a progressive lens (see earlier post here). And of course, as mentioned here, you need anti-reflective (no glare). Also, as with most people, you are quite light sensitive so you decide you would like Transitions as well.

Below, I will use some assumed coverages, based on how VSP Choice works (probably the most common insurance type):

USUAL & CUSTOMARY PRICE           AFTER INSURANCE
Frame:              $250                             $104
Progressive:     $400                             $150
No Glare:          $165                             $95
Transitions:     $130                             $86     
TOTAL              $945                              $435

You’ll notice that the after insurance cost is roughly half the original cost.  This is a very common result for VSP Choice.  Other plans may have variations on this theme (some cover much less, some quite a bit more).

One of the most important things to take away from this, is that your coverage will be the same ANYWHERE you go that is within network.   We don’t set these prices, your insurance company does.  So “price shopping” very rarely does anything at all for you.  What you want to shop for is the experience, customer service, and accuracy of your eyecare provider.

Take Away

Vision Insurance is not Medical Insurance.  It’s confusing, I know.  You would assume that since your vision is part of your overall health, it would be covered by the same plan, but it’s always been treated differently.  Understanding how your coverage works can be confusing.  Understand that your eyecare professional is there to help you sort through it.

And most importantly, the price is the price is the price.  Wherever you go, this will be the same.  When selecting who will get your eyecare business, choose based on service, talent, experience, and accuracy, not price.