We have written a few blogs about the importance of eye examinations for both adults and children, but the type of eye exam you have is also important to understand as it may result in different out-of-pocket costs depending on your health plan. This blog explains what a routine eye examination is, what a medical eye examination is, and when and why a routine eye exam may become a medical eye exam.
A routine eye examination is comparable to a routine physical exam. Both are preventive examinations scheduled when no known issues or conditions have been detected. During the exam, you’ll discuss your personal and family eye and health history with the clinician, have vision and refractive status (what if any prescription you need for glasses or contact lenses) in each eye checked, and receive a full eye health check with dilation. You may not have any symptoms but still could have an undetected eye disease that might be discovered during a routine eye exam. One of the common diseases that you could have but not know is glaucoma. You could also have a retinal condition that is also asymptomatic in early stages.
Medical eye examinations often consist of the same testing as a routine exam, but the reason for the visit is to pay special attention to a specific condition. A common example is diabetes. Diabetic patients should have a full eye examination with a retinal evaluation at least once a year. These examinations are considered medical, as the doctor is specifically looking for any signs of diabetes in your eyes. Other examples are dry eyes or cataracts.
If your doctor does find a chronic medical condition during a routine eye examination, your subsequent visits will most likely be categorized as medical, as the condition needs to be addressed and monitored for the long term.
Oh, I wish this was an easy question to answer, but vision benefits vary quite a bit among health insurance plans. Some insurers cover routine eye exams, some cover medical eye exams, and some cover both. And then in other cases, you may need to pay for certain services performed within an exam that are not covered by insurance. For example, sometimes determining refractive state (i.e., what prescription is best for you for eye glasses or contact lenses) is not covered by your insurance, so you may get a bill for the refraction portion of the exam even though insurance is paying the remainder of the exam. Similarly, most insurers do not cover contact lens fittings or annual contact lens examinations. As a result, you may have an extra fee for these exams even if the rest of the exam is covered by your insurance.
Understanding your insurance and your eye history can help you navigate what to expect for your eye exam coverage. We recommend that you always check your coverage prior to your eye appointment to know your benefits.