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Do you know the difference between medical insurance and vision insurance plans in Pennsylvania? It's important that you know what procedures and services are covered under vision insurance and what plans and services are covered by your medical insurance.
You might think that vision insurance covers everything related to the eyes, including glasses and contact lenses to diagnosis and treatment of eye diseases and medications. However, vision insurance is limited in its coverage. It is important that you understand that your Vision Plan (VSP, Davis, EyeMed, VBA) covers ROUTINE well-eye exams only (nearsightedness, farsightedness, and normal astigmatism) which includes the refraction to determine your eyeglass prescription. Some plans provide a limited contact lens evaluation/materials benefit while many others do not provide contact lens benefits. In addition, your plan may provide discounts or allowances towards eyeglass frames, lenses or contact lenses. As part of your routine well-eye exam, our doctors examine your eyes for many conditions and diseases including glaucoma, dry eyes, cataracts, retinal holes or tears, diabetic and hypertensive eye diseases, and many more.
If your routine well-eye exam reveals a medical condition or disease related to your eye that requires specific counseling, documentation, follow-up care, regular monitoring or referral to a surgeon, or if the exam is related to a pre-existing medical condition such as cataracts, glaucoma, diabetes, dry eyes, etc., then your visit is NOT COVERED by your Vision Plan. For instance, if you come in for a routine well-eye exam simply because you are having difficulty seeing with your current glasses, but it is found that your reduced visual acuity is due to developing cataracts, then your exam would have to be billed to your medical insurance. Unfortunately, the doctor cannot tell if medical eye conditions exist before you are thoroughly examined.
Medical insurance covers those eye care services that are medical in nature.
Diagnosis and management of eye disease -- including cataracts, glaucoma, floaters, dry eyes, eye infections or injuries, macular degenation , double vision, headaches, etc..-- is covered by medical insurance, not vision insurance.
Any appointment for eye disease diagnosis, treatment, or follow-up should be covered by your medical benefits, not vision insurance. Referrals for eye surgery, pre-operative surgical care, and post-operative surgical care for medical eye issues are all covered by medical rather than vision insurance. You do not need a vision benefits rider on your medical insurance to be covered for a medical eye condition, as it is covered in a similar fashion to the way that a visit to any medical specialist is covered. In these cases, your Medical Insurance will be billed for the eye exam even though a Vision Plan may also be in effect because you are being treated for a medical condition.
Your Medical Insurance co-pays and deductibles prevail and must be paid at the time of your exam. If a referral is required by your insurance plan in order to see a specialist, then you are responsible to obtain it. Additionally, if we do file the claim for your exam with your medical insurance, you can still use your Vision Plan material benefits towards the purchase of eyeglass frames, eyeglass lenses or contact lenses based on your specific plan's allowances.
This may all seem very confusing, but these are the rules set by your insurance company. If you still have questions about Vision vs Medical Insurance, we would be happy to answer any questions that you may have about your insurance coverage. Your job is to bring proof of insurance with you when you come, and to make sure that your insurance is accepted at our Allentown eye care clinic.