PATIENT RESOURCES

About Vision vs. Medical/Health Insurance Coverage for Eye Care

Today's health insurance policies can be incredibly confusing. Understanding your health insurance and vision benefits is not as easy as it once was, and the most common insurance questions we receive in the eye care field are related to the difference between vision and medical/health insurance coverage.

So, what is the difference between Vision insurance and Medical/Health insurance? Let's break it down below!

UNDERSTANDING INSURANCE COVERAGE

MEDICARE AND VISION COVERAGE

Routine eye care services, such as regular eye exams, are excluded from Medicare coverage. However, Medicare does cover certain eye care services if you have a chronic eye condition, such as cataracts or glaucoma. Medicare covers:

Surgical procedures to help repair the function of the eye due to chronic eye conditions. For example, Medicare will cover surgery to remove a cataract and replace your eye’s lens with a fabricated intraocular lens.
Eyeglasses or contacts if you had an intraocular lens placed in your eye after cataract surgery. In this case, Medicare will cover a standard pair of untinted prescription eyeglasses or contacts if you need them. If it is medically necessary, Medicare may pay for customized eyeglasses or contact lenses.
An eye exam to diagnose potential vision problems. If you are having vision problems that may indicate a serious eye condition, Medicare will cover an exam. Your exam is covered even if it turns out you do not have a vision problem.

Medicare only covers routine eye care in the following circumstances:

If you have diabetes, Medicare covers an annual eye exam by a state-authorized eye doctor to check for diabetes-related vision problems.
If you are at high risk for glaucoma, Medicare covers an annual eye exam by a state-authorized eye doctor. You are considered to be at high risk if you:
- Have diabetes
- Have a family history of glaucoma
- Are African American and age 50+
- Or, are Hispanic American and age 65+

Vision insurance coverage

Your vision insurance generally covers what your vision insurance considers to be routine or general eye care.

A routine eye exam is defined by vision insurance as an office visit for the purpose of checking your vision, basic screening for eye disease, and/or updating eyeglass or contact lens prescriptions (which requires refraction). These types of vision exams generally produce common diagnoses that include but are not limited to nearsightedness, farsightedness, and astigmatism.

Medical insurance coverage

Your medical insurance is typically used if you have a vision-threatening eye problem or eye disease, OR if you have a medical condition that is affecting your vision. Some common conditions covered by medical insurance (but NOT by vision insurance) include:

Patients with vision loss, floaters, dry eyes, allergies, infections, styes, etc.
Monitoring cataract development, examination of patients possessing diabetes
Examination of patients using medications with potential eye side effects, such as steroid medications, arthritis medications, etc.
Patients with or at are at high risk for glaucoma development, patients with macular degeneration

When you call in to make your next appointment with the eye doctor, make sure to explain the purpose of your visit so that we bill the appropriate insurance.

Additionally, please always bring your insurance card(s) with you to every appointment.

Can I use my vision insurance and my medical insurance for a joint exam on the same day?

VSP patients: We ARE able to bill the exam under your medical insurance and the refraction under your vision plan for same-day services.

For patients with most other insurances: By law, we generally cannot bill vision and medical insurance in one day. There are two alternatives:

We can schedule your medical and vision visits on separate days, allowing us to bill your insurance on different days. Note: you may need to repeat some parts of the exam for each visit because, by law, there are certain things the eye doctor must document at every visit.
If you need to schedule your medical and refraction exam on the same day, another option is billing your medical insurance for the medical exam (don’t forget, this may include a copayment at the time of your visit) and paying the additional flat rate for refraction ($75- see more on this below).

Why am I being charged a refraction fee?

A refraction test is usually given as part of a routine eye examination for the purpose of determining your glasses or contact lens prescription. It may also be called a vision test.

Vision insurance typically covers the cost of refraction.

Medical insurance DOES NOT cover the cost of refraction.

There is a $75 charge for determining your glasses prescription (refraction).

Additional charges may apply for determining your contact lens prescription.

What is optomap imaging and is it covered by my insurance?

For many years, the only way to get a good view of the retina was to dilate the eyes. This process involves the doctor placing special eye drops into your eyes to open the iris (the color part of the eye). When the iris is open, the doctor uses bright light and lenses to examine the nerves and blood vessels of the retina for signs of damage or disease. Unfortunately, despite its benefits, dilation is not always a pleasant experience for most patients.

Thankfully, for routine eye or vision exams, Clarus Eye Centre now offers an alternative to dilation called optomap imaging. This high-tech camera takes a wide-field, high-resolution, digital picture of the retina – without eye drops! (NOTE: This service is available for eligible patients only. Patients who require a higher level of retina care will still require dilation).

For eligible patients, OPTOMAP IMAGING IS FAST AND DOES NOT REQUIRE DILATION.

In addition to being faster and more convenient than dilation, optomap allows your doctor to show you what the back of your eye looks like, gives you a snapshot of your overall eye health, and provides an opportunity for you to discuss any questions or concerns that arise from any abnormal findings.

While the optomap has been a great addition to our practice, it is not a replacement for dilation. There are several instances in which dilation may be more appropriate than the optomap. These can include but are not limited to patients with extremely small pupils, droopy eyelids, dementia, certain physical disabilities, and emergency eye conditions.

At Clarus Eye Centre, we believe that optomap imaging and dilation are both important tools for evaluating the health of the retina, but one or the other may be a better option for you depending on your circumstances.

Your doctor will recommend which option is best for you.

PLEASE NOTE: Depending on the nature of your exam (routine or medical) and your insurance coverage, there may be a $39 fee associated with your optomap image.

Understanding your coverage vs. total amount owed

Insurance coverage does not always equate to payment. Many health plans have copayments and deductibles that must be met before your insurance will pay any amount towards your bill.
Check with your insurance carrier before your office visit to make sure you have vision benefits (and what they are), to confirm that our doctors are classified as providers in your plan, and to determine if refractions are covered under your plan.

To reach your insurance provider, you can call the phone number on the back of your insurance card or look up your insurance policy details online. Remember to ask your provider if your insurance includes vision or if it is for medical coverage only. Ultimately, it is your responsibility to understand the policies of your insurance companies, both medical and vision. However, we're happy to help in any way we can. Please refer to our billing contact information at the bottom of this page for further questions.

Payment Options

CONTACT OUR BILLING DEPARTMENT

The staff at Clarus is extremely knowledgeable about a variety of insurance plans. However, it is our duty to remind you that it is ultimately your responsibility to know the details of your individual plan and make sure you are aware of possible deductibles and co-pays associated with your type of plan.

If you aren’t sure of what your insurance covers, please contact us utilizing the call button or message form below.

We will do our very best to help you understand the nuances of your insurance plan so that you're able to get the quality eye care you need while avoiding confusion afterward.

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FOR CATARACT SURGERY PATIENTS

LEARN MORE ABOUT PREMIUM CATARACT SERVICES

CATARACT SURGERY FORMS AND INSTRUCTIONS

FINANCING OPTIONS FOR PREMIUM CATARACT LENSES

Clarus partners with Alphaeon Credit for patients who choose premium cataract lenses.

For more information or to find out if you qualify, please visit Alphaeon's website here:

LEARN MORE ABOUT ALPHAEON CREDIT

ADDITIONAL RESOURCES

Do you have Medicare Advantage?

Medicare Advantage offers a resource to help guide seniors through all of the available Medicare plans, eligibility requirements, enrollment guidelines, and their many benefits.

Learn more

Local Resources for Seniors

PATIENT RESOURCES

About Vision vs. Medical/Health Insurance Coverage for Eye Care

UNDERSTANDING INSURANCE COVERAGE

CONTACT OUR BILLING DEPARTMENT

FOR CATARACT SURGERY PATIENTS

FINANCING OPTIONS FOR PREMIUM CATARACT LENSES

ADDITIONAL RESOURCES

Do you have Medicare Advantage?

Local Resources for Seniors

Senior Services for South Sound

Lewis Mason Thurston Area Agency on Aging

WA State Department of Home & Community Services

For Referring Providers: Our Commitment to You

How to Refer a Patient:

Refer by fax:

Blake Perry, M.D.

Oculofacial Plastic and Reconstructive Surgeon

WHY HAVE I BEEN SENT TO A RETINA SPECIALIST?

WHAT IS A RETINA SPECIALIST?