Insurance FAQs

Insurance Frequently Asked Questions

What do Vision benefits cover?

Vision benefits are typically an added benefit to your Medical Insurance Plan. It is intended to provide basic "wellness" exam for refractive purposes such and nearsighted, farsighted, astigmatism diagnosis. In addition to the exam, there is typically an allowance for the material part for either glasses or contact lens benefits.
These plans will not cover any medical eye care. Medical eye care are any care beyond glasses/contact lens prescriptions, such as eye infections, dry eyes, floaters, diabetes, etc.

What do Medical insurances cover?

Medical Insurances will cover all medical related eye care. Even if you do not have any separate vision insurance, some medical plan will have routine exam benefits with refraction services embedded. Please call your insurance provider for more specific details or give our office a call and we will answer any questions you may have about your insurance coverage. If you do not have any routine exam benefits, you must have a Medical reason to be seen with your medical insurance.
For example, if you came in for an eye exam for blurry vision. It could be just vision changes due to uncorrected refractive error (which glasses will correct and vision benefits will cover) or it could be from diabetic retinopathy or cataract changes that causes blurry vision (which glasses could not correct and medical insurance will be used). Because this exam requires a much more in depth evaluation for a medical reason and not a "wellness" exam, this exam will be considered a Medical eye exam.

Why is it so complicated?

Good question! These are the rules set by insurance companies and all medical providers are required to follow them.

Is there a fee for my follow up visits?

Yes, there will be a fee associated with each office visit.

An example of what a Medical health insurance plan might offer:
  • Example:

    • In the example above, you would be responsible for the first $5,000 (your deductible).

    • After you have met your deductible of $5,000, you would be responsible for 20 percent coinsurance until you reach your out-of-pocket maximum of $6,000 (in this case, you would be responsible for another $1,000).

    • Your health insurance plan would pay the rest of the covered medical expenses (in this case, 80 percent).

    • After you have reached your out-of-pocket maximum, you would pay nothing for any additional covered medical expenses for the rest of the plan year.

Reference: "A Guide to Understanding Health Insurance." A Guide to Understanding Health Insurance. N.p., n.d. Web. 04 Aug. 2016.

Common Term Definitions
  • Co-payment

    • Co-payment: The payment you make, usually a fixed dollar amount such as $50, each time you visit the doctor or fill a prescription medication. Not all plans have co-payments. These typically do not accumulate toward the deductible and is due at each office visit.

  • Deductible

    • Deductible: The amount you're responsible for paying for covered medical expenses before your health insurance plan begins to pay for covered medical expenses each year.

    • Example: $5,000

  • Coinsurance

    • Coinsurance: Shared costs between you and the health insurance plan. For example, you pay 20 percent of costs and your plan pays 80 percent. These percentages may be different from plan to plan. Some plans may not have coinsurance.

    • Example: 20%

  • Out-of-pocket maximum

    • Out of pocket: The most you will have to pay for covered medical expenses in a plan year through deductible and coinsurance before your insurance plan begins to pay 100 percent of covered medical expenses.

    • Example: $6,000

*As a courtesy, our office will pull eligibility & benefits for your Medical Insurance and Vision Benefit Plans. We will provide estimated cost for your visit based on the information given and received at that time. We recommend for you to know your benefits and call your carriers prior to your visit, since estimated quotes are subject to change and you are ultimately responsible for knowing your plan and all financial obligations. All necessary information (member ID #, etc) must be available on the date of service for us to bill that carrier. If you find out after the fact you have coverage, please inform our office and we will be more than happy to provide you with an itemized Invoice for you to submit to your Medical Insurance or Vision Benefit Plans. Please contact us should you have any other questions. Thank you.

Helpful Articles
Back to Top