Medical vs. vision insurance

The difference between medical insurance and vision insurance comes down to the classification of the type of treatment you’re receiving. When looking at what insurance covers ophthalmologist visits, you’ll find your health insurance is used for coverage. Vision insurance, whether it’s group vision insurance or an individual policy, covers visits to the optometrist, but may also cover some treatments provided by an ophthalmologist. 

Here’s how each type of insurance covers vision care:

Medical insurance for vision

Medical issues with your vision are ones that require the help of an ophthalmologist for treatment and resolution. These issues are considered medical due to the fact you need a physician to treat the condition and prescribe medication, but not necessarily prescribe vision correcting aids such as glasses.

Vision insurance

So, what is vision insurance, especially if medical insurance covers certain types of vision care? Vision insurance provides coverage for eye exams, corrective lenses, eyeglass frames, contacts, and discounts on LASIK, special coatings for lenses and progressive lenses.

Does medical insurance cover eye exams? 

Medical insurance coverage for eye exams can vary depending on the specific policy and provider. Generally, most medical insurance plans do provide coverage for eye exams, particularly those deemed necessary for diagnosing and treating medical conditions related to the eyes, such as glaucoma, cataracts, or diabetic retinopathy. However, routine eye exams for vision correction purposes, such as obtaining a prescription for glasses or contact lenses, may not always be covered under medical insurance plans. It’s essential to review your insurance policy or contact your insurance provider to understand the extent of coverage for eye exams and any associated costs or limitations.

Importance of regular eye exams

An annual eye exam can help you maintain good, clear vision and overall eye health. Annual eye exams are not only for people with vision problems, these exams can also check the overall health of your eye, diagnose any issues, and treat any disorders. If you experience any problems with your eyes, such as pain or huge changes in vision quality, you’ll want to see an eye doctor right away.

Coverage details for routine eye exams

Under the Affordable Care Act (or ACA, also referred to as “Obamacare”), all qualified health plans must cover many eye diseases, including glaucoma, cataracts, amblyopia, strabismus, diabetic retinopathy, and age-related macular degeneration. These are all considered to be medical problems and are covered by your major medical insurance plan.

Additionally, the Obamacare qualified health plans are required to include pediatric vision coverage for all patients under 19 years of age, including an annual eye exam and eyeglasses, if necessary.

However, the overwhelming majority of qualified health plans under Obamacare don’t offer vision coverage for adults. This means that your major medical insurance plan quite possibly doesn’t cover vision problems due to refractive errors or mild but common eye diseases like conjunctivitis. So, if you need adult vision coverage, including coverage for an annual vision exam plus benefits such as eyeglass lenses and frames, partial coverage for LASIK procedures, and so on, you may want to consider purchasing a stand-alone vision insurance plan.

Finding in-network providers

When searching for in-network healthcare providers, it’s essential to utilize the tools provided by your insurance company to ensure you’re maximizing your benefits. Start by accessing the provider directory on your insurer’s website, where you can search for doctors, specialists, hospitals, and other healthcare facilities that are within your network. Choosing in-network providers typically results in lower out-of-pocket costs, as these providers have negotiated rates with your insurance company. Additionally, consider using eHealth’s resources to gain a better understanding of how to navigate your health insurance plan and find in-network providers effectively. Check out their guide on understanding health insurance networks for more tips and insights.

Does medical insurance cover eye surgery?

Many medical insurance plans do cover eye surgery, but the extent of coverage depends on various factors such as the type of surgery, the reason for the procedure, and the specific terms of your insurance policy. Generally, medically necessary eye surgeries, such as those performed to treat cataracts, glaucoma, or retinal detachments, are often covered by health insurance. However, elective procedures like LASIK or cosmetic surgeries may not be covered. It’s crucial to review your insurance policy carefully and consult with your insurance provider to understand what types of eye surgeries are covered and any associated costs or limitations.

Common eye conditions requiring surgery

Vision impairment: According to the CDC, the most common eye problems in the U.S. are due to refractive errors. Refractive errors in your eyes result in impaired vision, and include astigmatism (distorted vision), myopia (near-sightedness), hyperopia (far-sightedness), and presbyopia (inability to focus on close objects, usually in people aged 40 and older). Vision impairments such as these can often be corrected by eyeglasses or contact lenses and sometimes by surgery, such as LASIK.

Cataracts: Other common eye disorders include cataracts, which is essentially a clouding of the eye’s lens and is the leading cause of eyesight loss in the U.S. and worldwide. Stronger lighting and eyeglasses are initially effective against cataracts, but the majority of patients eventually require surgery, which can be quite safe and immensely successful depending on individual circumstances.

Glaucoma: Glaucoma, which causes damage to the eye’s optic nerve and can result in partial or total blindness, is another major eye disorder. In general, glaucoma is treated with medication (eye drops or pills) or surgery (traditional or laser). The goal is to prevent blindness in the patient.

Pre-authorization process for surgery

The pre-authorization process for surgery involves obtaining approval from your insurance provider before undergoing a surgical procedure. This step ensures that the surgery is deemed medically necessary and eligible for coverage under your insurance policy. Typically, your healthcare provider or surgeon will initiate the pre-authorization process by submitting a request to your insurance company. The request will include details about the planned surgery, such as the type of procedure, diagnosis, and anticipated date. The insurance company will review the request and determine whether the surgery meets their criteria for coverage. Once approved, you’ll receive confirmation from your insurance provider, allowing you to proceed with the surgery knowing that it’s covered by your insurance plan.

Frequently asked questions (FAQs)

What eye care services are typically covered by insurance?

Eye care services covered by insurance often include routine eye exams, treatment for eye diseases or injuries, prescription eyeglasses or contact lenses, and medically necessary procedures such as cataract surgery or treatment for glaucoma. However, coverage may vary depending on your insurance plan and provider.

How often can I get an eye exam covered by insurance?

The frequency of covered eye exams varies depending on your insurance plan and provider. Typically, most plans cover one comprehensive eye exam per year for adults. However, certain circumstances, such as changes in vision or underlying medical conditions, may warrant more frequent exams. It’s essential to review your insurance policy or contact your provider to understand your specific coverage and any limitations on the frequency of eye exams.

Can I use my insurance for LASIK or other elective procedures?

Whether LASIK or other elective procedures are covered by insurance depends on your policy and provider. In many cases, elective procedures like LASIK, which are considered cosmetic or optional, may not be covered by standard health insurance plans. However, some insurance policies offer optional vision or elective procedure coverage as add-ons or through separate vision insurance plans. It’s essential to review your policy or contact your insurance provider to determine if LASIK or other elective procedures are covered and what, if any, out-of-pocket costs you may incur.

What if my insurance doesn’t cover a necessary eye procedure? 

If your insurance doesn’t cover a necessary eye procedure, you may have several options to explore. Firstly, you can discuss alternative treatment options with your healthcare provider to find a solution that fits within your budget. Additionally, you may consider appealing the insurance company’s decision if you believe the procedure is medically necessary. Alternatively, you can inquire about self-pay or financing options offered by healthcare providers or explore government assistance programs for healthcare expenses.

Find vision insurance with eHealth

You don’t have to worry about getting coverage for vision care provided by an ophthalmologist, as your health care insurance typically covers the cost of care for physical issues with your eyes. However, you’ll need vision insurance to cover exams and corrective lenses. At eHealth, we want to help you save money and get the most out of your vision insurance. Check out our selection of vision insurance providers to learn more about vision insurance policies and how much they cost. 

We can help you find out more about the various vision plans available to help safeguard your eyesight.

• Just call eHealth agents at 1-866-787-8773, TTY users 711; Monday through Friday, 8AM to 8PM ET, Saturday, 9AM to 6PM ET.
• Or, visit eHealth’s vision insurance center and get a quote.

This article is for informational purposes only. Nothing in it should be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.