“Annual /Routine” vs. Medical Eye Exam

Vision Plan, Annual and Medical Eye Exams


Many commercial insurance plans through employers offer benefits of an annual/biannual eye exam and a vision “rider” that provides for a vision exam.  In addition recent publicity about “free” preventative services at both the state and Federal level has people believing that they can receive a “free” eye exam every year.  In this posting we are going to try to explain all of those various exams, the benefits covered and why some patients cannot take advantage of certain benefits because of chronic eye disease.


Benefits under most vision plans are limited to those services, provided by an ophthalmic or optometric provider, needed to evaluate your need for glasses/contact lenses or to adjust the prescription for your eyewear. The refractive exam is not intended to evaluate the complete medical health of your eyes. This exam will be billed to the vision services insurance plan named in the vision service “rider” (EyeMed, Davis Vision, VSP, etc.) to the patient’s health insurance.


If your insurance plan offers you an annual or biannual eye exam, that exam will be done without your having to pay a copay but the exam itself will be billed to your insurance plan.  This exam will evaluate the complete health of your eye and should involve dilation of the eye so the doctor can get a good at the back of your eye.


The third type of exam is a medical exam being done because of a complaint from the patient about an eye problem or a decrease in visual acuity.  With an exam such as this, the patient will pay a copay and the exam will be billed to their health insurance.  This exam will be as complete as the doctor feels is needed to address the issue that brought the patient to the office in the first place.  So it may or may not include dilating the patients eye.


There are no services required under the Federal Preventative Services Program or the Massachusetts version of preventative care program related to eye care except for a free screening for children under 6 who are supposed to be screened by their pediatrician in the pediatrician’s office.


Now the confusion comes when a patient presents at North Suburban Eye Associates, or any other ophthalmic or optometric office, for their vision plan exam but Dr. Evans finds a medical problem in the course of the refractive exam. Since the vision exam is not expected to deal with medical issues, Dr. Evans will present the patient with an option.  The vision exam can be completed and billed to the vision service plan and the patient will be asked to make another appointment to address the medical issues identified.  OR the patient and doctor can decide that the medical issues needs to be addressed during this visit so the patient is told that they will thus incur a copay and the exam will be billed to their medical insurance.  The patient can then make another appointment which will address their vision plan issues.  It is not acceptable under insurance regulations to bill both the patient’s medical insurance and their vision “rider” for the same office visit and North Suburban Eye Associates will not do so.


Some patients with chronic systemic conditions such as diabetes, which can have serious affects on the eyes, or chronic eye disease, such as glaucoma or macular degeneration, will, once those conditions are diagnosed, never qualify for a vision plan exam because it will be necessary to address their chronic condition at every visit with the eye doctor.  Their visits to their eye care provider will always be billed to their medical insurance.


Finally, patients with Medicare generally do not have these issues.  If there is an eye problem the exam will be billed to, and paid by, Medicare.  If the patient truly has no problems but still seeks an eye exam to check for a glasses or contact lens prescription, the patient will have to pay for that exam because it is considered by Medicare to be a “screening” exam and Medicare does not cover such exams.


The key here is that the expectations for what services the patient will receive for the different types of eye exams must be understood by the patient.  They need to understand the benefits offered by their health insurance plan and the differences between those services.  The exams are not interchangeable and the services covered under each type of exam will not be modified by providers at North Suburban Eye Associates to fit the desires of the patient.

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Vision Plan, Annual and Medical Eye Exams (DOC FILE)

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