Medical and Vision Insurance – It’s Complicated
Visionary Eye Doctors accepts most medical and vision insurance plans. The topic of insurance has always been a confusing one, especially in the world of eye care.
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A vision policy is not the same as health insurance.
It is important that you understand that your Vision Plan (Davis, EyeMed, among others) covers ROUTINE well-eye exams only (nearsightedness, farsightedness, and normal astigmatism), which includes the refraction to determine your eyeglass prescription. Some plans provide a limited contact lens evaluation benefit, while many others do not provide any contact lens evaluation benefit. In addition, your plan may provide discounts or allowances towards eyeglass frames, lenses, or contact lenses.
Depending on your eyes and medical history, we modify the exam to suit your needs. Our vision well-eye exams include: visual acuity testing, auto refraction, an undilated view of your eye, slit lamp exam, and a refraction test. The refraction test tells your eye doctor exactly what prescription you need in your glasses or contact lenses.
If you are having a vision exam using your vision insurance, the doctor will determine if a dilation is needed at the time of the appointment. For some, dilation may cause light sensitivity and blurry vision. Not all vision plans cover dilation.
Additionally, many vision insurance plans do not cover contact lens fittings (for first-time wearers or established wearers who need to switch to a new brand) or yearly contact lens evaluations (to make sure that the contacts you are wearing fit and allow your cornea to breathe).
If your routine well-eye exam reveals a medical condition or disease related to your eye that requires specific counseling, documentation, treatment and follow-up care, regular monitoring or referral to a surgeon, or if the exam is related to a pre-existing medical condition such as cataracts, glaucoma, diabetes, dry eyes, etc., then your visit is NOT COVERED by your Vision Plan. For instance, if you come in for a routine well-eye exam simply because you are having difficulty seeing with your current glasses, but it is found that your reduced visual acuity is due to developing cataracts, then your exam would have to be billed to your medical insurance. Unfortunately, the doctor cannot tell if medical eye conditions exist before you are thoroughly examined.
The good news is that your medical insurance can be used when an eye-related medical problem such as eye injuries, pink eye, double vision, headaches, cataracts, redness, itchiness, blurriness, dry eye, complications from diabetes, or high blood pressure (among many others) is indicated or found during the course of the eye examination. You do not need a vision benefits rider on your medical insurance to be covered for a medical eye condition, as it is covered in a similar fashion to the way that a visit to any medical specialist is covered. In these cases, your medical insurance will be billed for the eye exam even though a vision plan may also be in effect because you are being treated for a medical condition.
Your medical insurance co-pays and deductibles prevail and must be paid at the time of your exam. If a referral is required by your insurance plan in order to see a specialist, then please note, it is your responsibility to obtain the referral. Additionally, if we do file the claim for your exam with your medical insurance, you can still use your Vision Plan material benefits toward the purchase of eyeglass frames, lenses, or contact lenses based on your specific plan’s allowances.
Unfortunately, due to policies of the insurance companies, you cannot use your vision and medical insurance for a joint exam on the same day.
At times, it can seem like a complicated process, and please note these policies are set by your insurance company. If you may have further questions about Vision vs. Medical Insurance, please give us a call and we will be happy to answer any questions that you may have about your insurance coverage. (301) 591-1763
Do you take my insurance?
Please note: While we accept most insurance plans, some of our doctors participate only in certain plans. If the doctor you choose to see does not participate in your plan, you are welcome to see another doctor or receive care as a self-pay patient regardless of your insurance coverage. We encourage you to call our billing manager to learn about other means of financing your eye and vision care or call our benefits specialist to gain a clearer understanding of what benefits your insurer allows.
We do accept Medicare and most Medicaid plans for Maryland and DC.
Do I need a referral for an eye exam?
Depending on your insurance, a referral may be required. Please contact your insurance company for more information.
Why do I still owe a balance if my insurance company has paid Visionary Eye Doctors directly?
Although you may be paying a hefty monthly premium for your health insurance (or a percent of what your employer pays), your health plan most likely does not cover 100% of the cost of your health care. It most likely covers approximately 80% of the cost of your health care. Additional costs (or out-of-pocket expenses) that you may be responsible for may include an annual deductible, co-payments, and co-insurance.
What is a deductible?
A deductible fee is an amount you have agreed upon with your insurance company that you must pay out of pocket before your insurance pays for the remainder of your authorized services. If you have not met your deductible, we will submit the claim and discuss with you the amount of your deductible that is your responsibility to pay. The amount is paid directly to Visionary Eye Doctors, and your insurance company will be notified of this amount when the bill has been submitted, so your insurance can update any deductible remaining or update that your deductible has been met.
What is co-insurance?
Your share of the costs of a covered health care service is calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance’s or plan’s allowed amount for an office visit is $100, and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Please note if there is any co-insurance fee, we will discuss this with you prior to services being provided.
What is a co-payment?
A co-payment (or co-pay) is a fixed-dollar amount that you pay each time for certain services. Most commonly, you will be responsible for a co-pay each time you have a doctor’s visit and for each prescription medication you fill. For example, typical co-payments may be $20 for each primary care physician visit and a $35 co-payment for a specialist visit. Co-pays are most often used in HMOs and for services you receive from a network provider in a PPO.
I don’t have insurance, can you help me?
Visionary Eye Doctors offers a discount to self-pay patients who pay 50%, (with the exception of surgical or procedures, please contact surgical for the payment requirements) or an earlier agreed upon amount, at the time of your appointment or procedure. We can assist you in setting up a payment plan. Additionally, we offer Care Credit, which has many payment options, including plans with no finance charges that are available. Please call (301) 591-1763 to be connected to our billing department during our normal business hours 8 a.m. to 5:30 p.m., Monday through Friday, or you may send us an email. If it’s after hours, we will respond back to you the next business day.
Why is the contact lens evaluation fee separate from the comprehensive eye exam fee?
Comprehensive eye exams include tests that determine general eye health and refractive status (i.e., eyeglass needs). Contact lenses are medical devices that may have certain health implications if not prescribed correctly. Your doctor must invest additional time and expertise to determine which contact lenses are in a patient’s best vision and health interest, and there are additional fees for this service. Note: Sometimes, this requires additional follow-up visits as well.
Insurance companies view most contact lenses as elective vision correction and generally offer a discount toward the contact fitting fee. On rare occasions, insurance companies may consider contacts as medically necessary and cover a portion or all of a contact fitting, such as those for patients with conditions like keratoconus. Most insurance companies take the position that if your vision can be corrected with glasses, then contacts are not medically necessary and therefore are not covered as extensively as glasses and your annual eye exam.
Do I need to be evaluated every year for my contact lenses?
Contact lenses come in “contact” with the delicate surface of your eye and, over time, can change the status of the health of your eye. Contact lenses are also considered “medical devices” as they are directly placed on your eye; this means an evaluation needs to be done every year even if the prescription does not change. Most health conditions that contact lenses can be responsible for causing don’t result in obvious symptoms like pain or vision change — only your doctor can determine if contact lens wear continues to be safe with your most recent prescription. Most experienced doctors agree that one year is a suitable amount of time between checkups to ensure your eye health, given you are relatively symptom-free.
What’s the difference between a standard contact lens therapy and a specialized contact lens therapy?
Standard contact lens therapy involves correcting vision for one standard challenge such as nearsightedness or farsightedness.
Contact lens therapy that requires treating astigmatism, bifocal vision, or other special conditions requires deeper knowledge and more time invested on your behalf. This level of therapy is deemed “premium” and, subsequently, results in a different fee level.
How much are contact lenses?
Each brand of contact lens has its own related price, but generally, our prices are matched to what you might find anywhere. We also offer value-added services for patients who purchase their year’s supply from our office, such as discounts or glasses specials. We also provide services, such as easy box return and/or exchange and free trial lenses when you’re running low (for patients who purchase their year’s supply from us).
Should you have any questions about your bill, please reach out to our billing specialist at: (301) 591-1763. Alternatively, we offer an online payment option for your convenience.