Vision Plan or Medical Insurance; who covers what?

Vision Care Plans are often an add on rider of your Medical Insurance intended to pre pay and provide a service and a durable good at a reduced fee.  It is limited to a refractive diagnosis with the doctor performing a screening evaluation of the health of the eye. Vision plans such as VSP, cover vision diagnosis known as nearsighted, farsighted, and some forms of astigmatism.

Medical care involves situations where during the course of the evaluation, a medical condition that requires a management decision related to your eyes is made. In these situations there is a need or indication for counseling, documentation, follow-up care, monitoring, and/or prescription of medications or referral to a surgeon.


1. What does my Vision Plan cover?

Your vision plan is intended for “well eye” or routine exams.  This includes your eyeglass or contact lens prescription, and a screening for eye diseases or disorders and no medical decision or management is required.  Most vision plans are limited to one office visit and a partial coverage or discount for eyeglasses, and/or for contact lenses.


2.  What does my Vision Plan NOT cover?

Vision plans do not cover medical eye care (floaters, dry eyes, allergy, lazy eye, vision loss, foreign bodies, infections and such). Medical Insurance does not cover glasses or contacts or services related to eyeglasses and contact lenses.


3.  What does my Medical Insurance cover?

If you are having a problem with your eyes or vision that is found to be caused by a medical condition or problem, then your exam is considered medical in nature and must be submitted to your medical insurance plan.  For example, if your are having difficulty seeing with your glasses, and the doctor finds that your blurry vision is caused by cataracts, then your exam is considered medical. Likewise if there is a need to prescribe any medication to treat any condition.

If you have a pre-existing condition or any disease that can affect vision or cause blindness (cataracts, glaucoma, dry eye, diabetes, high blood pressure, cholesterol, etc.) then your exam will be considered medical. These services will be covered by your major medical insurance. We are providers for many medical insurance plans. Please see our Insurance page for a list of plans for which we are providers.  Vision plans do not cover medical eye care.


4.  How do you decide whom to bill? Can I or you decide beforehand?

No, the patient does not have the medical knowledge and the doctor does not know beforehand.  At the time of service, we require information for both entities (Vision Plans and Medical Insurance Plans). Once the doctor has evaluated you, the billed entity is determined by the final diagnosis and treatment pan (what you have and what we are going to do).


5.  Why is this so complicated?

As participating Providers, we are contractually bound to adhere to the billing policies and protocols established by your insurance company.  As the patient, you also have a contractual obligation with your insurance company.  Please contact your insurance carrier for a complete explanation of these policies and protocols.


6. Can I use my Vision Plan and Medical Insurance the same day?

Even if your eye exam is billed to your medical insurance, you may still use a vision plan benefits to purchase eyeglasses or contact lenses that same or at a later date.


7.  I still have questions…

We would be happy to answer any questions that you may have about your insurance coverage.  You may need to consult with your insurance company, vision plan, or human resources department directly to find out the specific coverage details and limitations of your plan.


Be mindful that until the doctor evaluates you, there is no way of determining which coverage will apply.