Understanding Your Insurance

MEDICAL INSURANCE VS. VISION PLANS: UNDERSTANDING THE DIFFERENCES FOR YOUR EYE CARE

At First Sight Vision Care, we often see patients with both vision plans (like VSP, EyeMed, Davis Vision, etc.) and medical insurance (such as Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, or Medicare). It’s essential to understand the differences between these types of coverage to ensure you get the most out of your visit and the proper benefits applied. Below is a breakdown of each type of insurance and how they apply to your eye care services.

Vision Plans: What They Cover

Vision plans are primarily designed to cover routine eye care needs and prescription eyewear:

• Routine eye exams: These exams are for patients who are healthy and do not have any symptoms or eye issues.
• Eyeglasses and contact lenses: Vision plans typically offer discounts or partial coverage for glasses and contacts.
• Annual wellness evaluation: This includes the general health check-up for your eyes, including assessing for common refractive issues like nearsightedness, farsightedness, or astigmatism.

Limitations of Vision Plans:

• Medical conditions or eye problems: Vision plans do not cover eye diseases, injuries, or conditions like glaucoma, cataracts, macular degeneration, dry eyes, or pink eye (conjunctivitis).
• Contact lens evaluations: Some vision plans may cover a portion of the cost of a contact lens evaluation and fitting but often not the full amount.

Refractions: In some cases, vision plans may not cover refraction (the test used to determine the best prescription for glasses or contacts), and patients may be asked to pay an additional fee for this service.

Medical Insurance: What It Covers

Medical insurance is designed to cover health-related issues, including conditions that affect your eyes. It includes coverage for medical diagnoses and treatments for a variety of eye diseases and conditions.

What Medical Insurance Covers:

• Eye diseases and conditions: If you have an eye condition like diabetes-related eye issues, glaucoma, cataracts, pink eye, or an eye infection, medical insurance will cover the cost of the examination and treatment related to that medical condition.
• Eye injuries: If your eye is injured or there’s a problem related to your eye health (such as a scratch, infection, or trauma), medical insurance will be used to cover the costs.
• Medical diagnoses: If your eye health is affected by systemic health conditions, such as high blood pressure, high cholesterol, or diabetes, medical insurance will apply.

What Medical Insurance Does Not Cover:

• Routine eye exams: Medical insurance does not cover routine vision exams, such as those needed to update glasses or contact lens prescription.
• Eyewear: Medical insurance does not cover glasses, contact lenses, or related purchases.

Refractions: Medical insurance typically does not cover the refraction portion of the exam, even if it’s necessary for medical reasons. Our fee for refraction is $55, which the patient will be responsible for paying.

How Both Insurances Work Together

Many patients have both a vision plan and medical insurance. Understanding how to use both can ensure you’re making the most of your coverage.

• Primary vs. Secondary Insurance: If you have both types of insurance, the one that is considered your “primary” insurance (usually based on which policyholder is the primary earner in your household) will be billed first. If you have secondary insurance, it may help cover any remaining costs. You’ll likely need to submit the claim for secondary coverage yourself unless you have prearranged coordination of benefits with your insurance. Typically Medicare will work with you to arrange coordination of benefits with your secondary coverage. 

• Coordination of Benefits: If you have secondary insurance, your benefits may not be automatically coordinated, and you may receive a statement showing any outstanding balance. First Sight Vision Care cannot file secondary claims on your behalf, but we can provide an itemized statement for you to submit to your secondary insurer.

Important Note: Insurance benefits cannot be retroactively applied to services or purchases made after the date of service. Be sure to check your eligibility and benefits before your appointment to avoid surprises. The key difference between vision plans and medical insurance is that vision plans focus on routine eye care and prescription eyewear, while medical insurance covers medical issues and treatments related to the eyes. It’s crucial to know which plan applies to your specific needs, whether you’re having a routine eye exam or seeking treatment for a medical condition. At First Sight Vision Care, we are committed to assisting you in maximizing your insurance benefits and providing you with the best possible care.

Please be sure to provide us with your most up-to-date insurance information so we can ensure your benefits are applied accurately on the day of your visit. If you have any questions or need help with your insurance coverage, our friendly team is here to help!