Vision vs. Medical Coverage

Your exam may be covered by a vision plan or by your regular medical plan. If it is a routine anual exam your vision plan will apply. If it is a visit for any non routine concern your medical plan will apply.

Non routine examples are infections, dry eyes, headaches, pain, finding anything other than a glasses prescription change. Medicare also will help out if we find cataracts, retina issues, infections, etc. The part where we are checking your glasses prescription is called refraction It is never covered by medical insurance or medicare. This is because it is considered by insurance to be a routine procedure not related to a medical issue that has developed.

Frequently Asked Questions

If I don’t have a vision plan, may I get an eye exam?

 

Yes

Comprehensive eye exams can be covered under any standard health insurance provided the appropriate copayment has been made and/or deductible met in addition to the following:

  • There is a medical diagnosis that relates to the eye, visual system and/or associated structures and is symptomatic, or has been previously diagnosed
  • You have a diagnosed systemic disorder with established risk to eye health

If I have a complaint such as a red eye will my vision insurance cover it?

No

Any health-related complaints will be considered a medical eye examination and typically covered under your regular health insurance. Some examples are listed below.

Medicare

Once your deductible has been met, Medicare will cover an office visit or comprehensive exam for any medical complaint relating to the eye or visual system. Medicare also offers coverage for examinations if you have a diagnosed systemic disorder with established risk to eye health. In addition the majority of additional testing that may be required may be covered by Medicare with the appropriate diagnosis. Coverage may differ between individual plans.

Refraction (determining the prescription for glasses) and the glasses and/or contact lenses themselves are typically an out-of-pocket expense, or covered by a Medicare Advantage plan.

What's the Deal

Are eye exams covered under health plans or vision plans?

Both

Eye care is a field of health care where both health insurance and vision insurance provides coverage. Typically, vision plans will cover annual or biannual preventative eye exams, along with some coverage toward glasses or contact lenses. Additional charges for glasses or contact lenses may apply based on your plan.

Do I need a yearly exam if I see well?

Yes

A comprehensive eye exam does many things besides check vision. Detection of diabetes and high blood pressure as well as medical eye conditions such as macular degeneration and glaucoma are included in comprehensive exams. Because these conditions can be detected before symptoms appear, the eye exam is a preventive service.

A Few Examples of What Insurance Covers

Medical Plan

  • Sudden loss of vision
  • Eye pain
  • Lazy eye
  • Double vision
  • Pink eye
  • Spots/floaters
  • Eye injury and/or foreign body
  • Eye allergies
  • Dry eyes
  • Styes
  • Ocular migraines
  • Headaches
  • Diabetic eye exams
  • Contact lens complications including ulcers
  • Glaucoma and cataract diagnosis, co-management, and referrals

Vision Plan

  • Myopia (nearsighted)
  • Hyperopia (farsighted)
  • Presbyopia (difficulty focusing)
  • Astigmatism
  • Computer eye strain
  • Lenses
  • Frames
  • Contact lenses
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