Practical guide
Vision plan or medical insurance: which one covers your visit
This page is about coverage, not care. If you have an urgent eye problem, call first and sort out the insurance afterwards. Same-day slots are held. Call (609) 246-0236. If the office is closed, or you cannot reach us, go to a hospital emergency room — most have an ophthalmologist on call.
Eye care is the one part of medicine where most people carry two kinds of coverage that do different jobs, and the rules about which one applies were written by the payers rather than by anyone trying to make sense to a patient. This page explains those rules in plain terms, so the answer at the desk is never a surprise.
The two kinds of coverage
- A vision plan (EyeMed, Davis Vision, UnitedHealthcare Vision, Superior Vision, VSP) is a benefit for healthy eyes. It covers a routine eye exam, the measurement of your glasses prescription, and an allowance toward glasses or contact lenses, usually once a year.
- Medical insurance (Horizon, Aetna, Cigna, UnitedHealthcare, Humana, Clover, Medicare) covers eye problems: a symptom, a condition, a test ordered because of one, and monitoring of a disease or a medication. It treats the eye the way it treats any other part of the body, with the same copays and deductible.
The same visit, in the same chair, with the same doctor, is billed to one or the other depending on why you came and what was found. That is the rule, and the office does not get to choose it.
What decides which one applies
The reason for the visit. If you come for a routine check and new glasses, it is a vision plan visit. If you come because of a symptom, a condition you have, a medication you take, or because another doctor sent you, it is a medical visit, whatever else is done while you are here.
- Vision plan
- "I am due for my yearly exam." "I need new glasses." "My contacts need renewing." A routine exam with no symptoms and no eye disease.
- Medical insurance
- A red eye, dry eye, flashes or floaters, something in the eye. Diabetes, glaucoma or a glaucoma suspect, macular degeneration, a cataract being followed. Screening for Plaquenil or a GLP-1. A visual field or scan ordered because of a finding. A visit a physician referred you for.
- Both, on different days
- A routine exam that turns up a problem is still billed to the vision plan. The follow-up for the problem is a medical visit. The two are kept separate on purpose.
One line that catches people out: the measurement of a glasses prescription (the refraction) is a vision plan service. Medicare and most medical plans do not pay for it, even during a medical visit, so when it is done at a medical visit there is a separate, modest charge for it unless a vision plan covers it.
What Medicare covers, and what it does not
- Covered: medical eye visits; a yearly diabetic eye exam; a yearly glaucoma test for people at higher risk (diabetes, family history, African American aged 50 or over, Hispanic aged 65 or over); tests and monitoring for eye disease; cataract surgery and one pair of glasses after it.
- Not covered: routine eye exams, the refraction, and glasses or contact lenses in general. Many Medicare Advantage plans add a routine exam and an eyewear allowance; check your plan.
Plans this office is in network with
- Vision plans: EyeMed, Davis Vision, UnitedHealthcare Vision (Spectera), Superior Vision.
- Medical plans: Horizon Blue Cross Blue Shield, Medicare, Aetna, Cigna, UnitedHealthcare, Humana, Clover.
- VSP is out of network, but we bill VSP directly for you, so on plans with out-of-network benefits you are not paying the full fee up front or filing a claim yourself. What VSP pays depends on your plan, and some VSP plans have no out-of-network benefit at all. Call with your plan details before you book and we will tell you where you stand.
How to avoid a surprise
- Bring both cards, every time. Which one is used depends on how the visit goes.
- Say why you are coming when you book. "Yearly exam" and "my eyes have been burning for a month" are different visits before you arrive.
- Ask before a test, if cost matters to you. If you are not sure whether a test carries a charge on your plan, call and we will check with the plan before your appointment rather than after.
- Know what a referral does. Some medical plans need a referral from your primary care doctor for a specialist visit; others do not. The plan's phone number on your card answers this in a minute.
- Your prescription is yours. You leave with a copy of your glasses prescription at no charge, and your contact lens prescription once the fitting is complete, and you may fill either anywhere. The exam and the eyewear are separate decisions.
Common questions
I only have medical insurance. Can I still have an eye exam?
Yes. If you have a symptom or a condition, it is a medical visit and is covered like any other. If you simply want a routine check and glasses, the exam is self-pay at the routine exam fee, with the prescription included. Call and we will tell you the fee before you book.
I came for a routine exam and you found something. Why was the follow-up billed differently?
Because the payers require it. The routine exam went to your vision plan. The follow-up visit for the finding is a medical visit and goes to your medical insurance, with its copay. Keeping them separate is what lets the vision plan pay for the routine part at all.
Why is there a separate charge for the refraction at a medical visit?
The refraction is the measurement of your glasses prescription. Medicare and most medical plans classify it as routine and do not pay for it, even when it is done during a medical visit. If you have a vision plan, it usually covers it; if not, it is a modest separate charge, and you can ask for it to be left out of a medical visit if you do not need a new prescription that day.
Do you take my plan?
The list above is current. Plans change their networks from time to time, so if yours is not listed, or you are not sure which product you have, call with the card in your hand and we will check.
Still not sure? Call
Call with your plan details before you book and it can be sorted out beforehand rather than afterwards. It takes a few minutes and it is the question we are asked most.
Khoury Eye Care, Hamilton Mall, 4403 Black Horse Pike, Mays Landing.
Sources
The figures and recommendations on this page come from the following. Ask at your visit if you would like a copy of any of them.
- Centers for Medicare & Medicaid Services. Medicare coverage: eye exams, glaucoma tests, diabetic eye exams, and eyeglasses after cataract surgery. medicare.gov.
- Federal Trade Commission. Ophthalmic Practice Rules (Eyeglass Rule), 16 CFR Part 456, and the Contact Lens Rule, 16 CFR Part 315: release of prescriptions to patients.
- American Optometric Association. Vision benefits versus medical insurance: guidance for patients. aoa.org.