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Annual Vision Exams vs. Medical Eye Exams - What's the Difference?

Many commercial insurance plans through employers offer benefits of an annual or biannual eye exam through a vision benefit plan “rider” that provides for a vision exam. Some medical insurance covers an annual eye exam without a vision rider and other medical insurance does not cover a comprehensive eye examination at all. Yes, we know this is confusing (but these are the insurance companies’ rules, not ours)! In today’s post, we will explain the various exams, the benefits covered and when each of the benefits apply.

Benefits under most vision benefit plans (VBP) are limited to those services required to evaluate your need for glasses and/or 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 your VBP (EyeMed, Superior, VSP, etc.) when one is available.

If your medical health insurance plan includes an annual or biannual eye exam (generally as part of your wellness benefits), that exam will be done without having to pay a copay but the exam itself will be billed to the medical insurance plan. Regardless of how it is billed, these exams will evaluate the complete health of your eye and will likely involve dilation of the eye so the doctor can get a good at the back of the eye. This type of exam is often referred to as a “routine,” “annual,” “refractive” or “comprehensive” eye exam. This type of exam is not appropriate for the treatment or management of any ocular disease.

The other 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 a medical exam, the patient will pay a specialist copay and the exam will be billed to the patient’s 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. Medical insurance generally does not cover the refraction portion of the exam so that is generally an out-of-pocket expense for patients who no longer qualify for routine eye exams. One positive is that unlike the exam covered by the VBPs, medical examinations of the eye can happen whenever necessary. For instance, if you have to be seen twice in one year due to ocular complications from diabetes, both examinations would be covered by your medical insurance.

Now the confusion comes when a patient presents for their VBP exam but the doctor finds a medical problem in the course of the exam. Since the VBP exam is not expected to deal with medical issues, the doctor will present you with two options. The vision exam can be completed and billed to the VBP and you will be asked to make another appointment to address the medical issues identified – OR – you and the doctor can decide that the medical issue needs to be addressed during this visit and you will thus incur a copay and the exam will be billed to your medical insurance. If necessary, you can then make another appointment to address any unresolved vision issues. In some instances, we are able to bill the VBP for the refractive portion of your exam and the medical plan for the remainder (coordination of benefits) which saves you from having to pay for the refraction (and sometimes more) out of pocket.

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 VBP exam again 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 medical insurance.

Finally, patients with Medicare generally do not have VBPs and Medicare does not cover routine (refractive) eye exams. If there is an eye health problem the exam will be billed to, and paid by, Medicare (excluding the charge for the refraction). If the patient has no ocular health concerns but still seeks an exam to check for a glasses or contact lens prescription, the patient will have to pay for that exam out-of-pocket because it is considered by Medicare to be a “screening” exam and Medicare does not cover such exams.

The key here is that you, the patient, need to understand the benefits offered by your health insurance plan and VBP (if any) and the differences between those services. The exams are not interchangeable and the services covered under each type of exam can not be modified to fit the desires of the patient.


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