Understanding Medical vs Vision Plans

We understand that insurance coverage for eye care can be confusing and frustrating. Many patients are surprised to learn that there is a difference between a routine vision exam and a medical eye evaluation, and how these differences affect insurance coverage and billing.

A vision exam is typically performed to update glasses or contact lens prescriptions and is often covered by vision insurance plans. A medical eye exam is performed when there is a medical concern, such as glaucoma, cataracts, diabetes-related eye monitoring, dry eye, infections, or other eye health issues. These visits are billed to medical insurance, similar to visits with your primary care physician or other specialists.

When an eye exam includes medical evaluation, testing, or treatment, it cannot be billed as a routine vision exam. Vision insurance covers prescription-related services only and does not apply to medical eye care.

Our priority is your eye health and long-term vision. We use advanced technology and clinical testing to detect eye disease early, often before you notice any symptoms. While insurance coverage can be complicated, our team is always happy to explain your visit, your coverage, and any charges.

If you have questions about your visit or insurance, please contact our office. We are here to help.

• The type of insurance billed is based on the reason for your visit and the doctor’s medical findings.

• If you have both vision and medical coverage, we will determine which plan applies for today’s visit.

• Sometimes, both types of coverage may be used — for example, a medical exam may be billed to your medical insurance, while a separate refraction (glasses prescription check) may be billed to your vision plan or paid out-of-pocket.  Many insurers however, do not accept this.

• Your insurance coverage is ultimately a contract between you and your insurer. You are responsible for any services not covered.

✅ If you have any questions about your coverage, please ask our staff before your exam. We are happy to help you understand your benefits.

Flexible Spending Accounts/Health Saving Accounts 

Many employers are offering Flexible Spending Account (FSA) or Health Saving Account (HSA) options to employees. Sometimes these are referred to as cafeteria plans and are elective supplemental savings plans. These plans are designed to let you save money in an account, pre-tax, to pay for additional medical expenses such as eye exams, glasses, contacts, and often laser vision surgery. Check with the benefits administrator at your work to see if you are eligible for this program. FSAs and HSAs can typically be used in conjunction with any vision insurance plan to offset any out-of-pocket costs on your behalf.