Routine eye exams are important even when our eyes and vision seem fine. This is because many blinding eye diseases have few or no warning signs until it is too late, and they have taken away some or all of our vision.
There are essentially two types of insurance plans that cover eye exams: vision insurance and health insurance plans. Many people are confused by the difference between them when it comes to paying for their eye exam.
It is little wonder, as there are so many different permutations to the two types of plans, with different deductibles, co-pays and levels of coverage. To help you understand what exams are generally covered under which type of plan, we’ve developed this FAQ based on questions our patients often ask us.
The biggest difference is that vision plans cover “routine eye exams”, glasses and/or contact lenses, whereas medical insurance plans do not. Medical insurance plans cover disease or injury to the eye, and therefore generally cover only “medical eye exams”.
There can be similar steps and tests within both types of exams, but insurance companies focus on the reason for your visit to an eye doctor to determine your coverage.
It really depends on your “chief complaint” – that is, why you want to see an eye care professional in the first place. If you want to book an annual eye exam, or wear glasses and think you may need your prescription updated, then you would book a routine eye exam, which your vision plan would cover. However, if you also have a medical problem, such as itchy, dry, burning eyes, then that would NOT be covered by your vision plan. We would file a medical claim for treatment of any medical problem.
A routine eye exam involves a series of different tests and usually produces a diagnosis of nearsightedness, farsightedness, astigmatism or presbyopia, along with a prescription for corrective eyeglasses or contact lenses, if required.
If you don’t have a vision plan, you must pay for your routine eye exam out of pocket at the time of the exam.
If you are suffering from an eye disease or condition, such as glaucoma or diabetic retinopathy, or suffer from dry eye or have an eye injury, then you would book a medical eye exam. The medical exam would be covered by your health insurance plan. Again, if you don’t have health insurance coverage, you would have to pay for the exam out of pocket or use our payment plan.
Note if you ever incur an eye injury, call our office immediately and you’ll be seen as soon as possible. After regular office hours, phone 855‑654‑2020 and press 5; the “doctor on call” will return your call promptly. Alternatively, call the emergency department at your nearest hospital.
If you booked a routine eye exam, your eye doctor will complete that exam and your vision plan would be billed. Your doctor will then schedule a follow-up medical eye exam to do additional tests and diagnose the possible eye disease. The follow-up medical eye exam would be billed to your health insurance plan.
Yes, or more frequent exams if your doctor deems them necessary, but once you are being treated for a medical eye condition, you would be booked in for a medical eye exam, and your health insurance would be billed.
A refraction is an essential part of a comprehensive eye exam that determines your eye’s best vision and prescription. It is the test where the doctor asks: “Which lens is better, one or two”? It measures nearsightedness, farsightedness, astigmatism or presbyopia. The doctor places an instrument called a phoropter in front of your eyes. You are shown a series of lens comparisons and indicate which is clearer. The results of the test are used to develop your prescription and monitor any changes in your vision.
If a patient is experiencing blurred or decreased vision, refraction determines if this is due to a need for corrective lenses or a medical problem. For patients anticipating cataract surgery, a refraction is required to prove that vision cannot be corrected with glasses and eye surgery is medically necessary. Patients who have a refraction will receive a new prescription valid for one year.
Our doctors consider refraction a critical component of any eye exam. It is the best way to monitor any changes in your vision over time.
Typically, vision plans cover both the eye exam and the refraction component. However, most health plans only cover the exam, and not the refraction.
Our fee for a refraction is $80, but we offer a $30 adjustment when it is paid directly at check-out (net fee is $50). If you do not have vision plan coverage for a refraction, you will have to pay for it at the time of your appointment. If you have coverage through a vision plan, we will bill your insurer.
Medicare, Medicaid, and private Health Insurance Plans generally do not cover “routine” eye exams or refraction fees. They are designed to cover the diagnosis and treatment of medical eye conditions and diseases.
If you or members of your family need corrective eyewear, you should consider purchasing a vision plan as they can save you considerable amounts on eye exams, glasses and contact lenses. Some vision plans also provide discounts for Lasik, PRK and other services with their contracted providers. Clemson Eye ia a contracted provider for a wide array of insurance plans.
Whether it is routine or medical, a comprehensive eye exam costs from $60‑$200, depending on the tests required. All co‑pays, deductibles, and shared costs are payable on the date of service. If you do not have insurance coverage, you are required to pay for your eye exam at the time of your appointment.
A comprehensive, dilated eye exam is the best way to protect your eyes and visual health over time. It’s important to know that many eye diseases have no symptoms until it is too late and vision has already been permanently lost. But if eye diseases, such as glaucoma, macular degeneration, cataracts, or diabetic retinopathy, are detected early enough, they can be treated and vision can be saved. We strongly encourage you to have a regular eye exam.
A comprehensive eye exam generally takes an hour and includes most of the following tests:
No one’s denying that figuring out health insurance coverage can be confusing. We at Clemson Eye are knowledgeable about coverage and will do our best to help you understand your particular plan’s benefits. However, it is your responsibility to understand your coverage, including any deductibles and co-pays. When in doubt you should review your policy carefully and/or contact your provider with your specific questions.