What is the Difference Between Eye Insurance and Health Insurance?

The main difference between eye and health insurance is in the findings during the eye examination. For most patients during the eye examination we find a new glasses or contact lens prescription to correct their vision problems. With these general exams, eye insurance covers most of the cost of the exam and part of the cost for the glasses or contacts. All vision or eye insurance coverages vary. Depending on the plan, the amount of the co-pay and materials coverage can be different. The co-pay is the amount the patient has to pay for the visit. Certain plans will cover the fee for fitting contact lenses, but most don't. Materials coverage or the amount insurance will pay for glasses or contacts varies also. Most vision plans offer around $100 towards glasses or contacts. There can be additional rebates with glasses, since most plans offer lower rates on glasses add-ons such as no-line bifocals, transitions, anti-reflective coatings, etc. Eye insurance can help pay for a general eye exam along with glasses or contacts. If there is a medical findings during the eye exam, then medical insurance is often utilized. Examples can include corneal infection, cataracts, glaucoma, macular degeneration, diabetic retinopathy, etc. Medical insurance helps cover the cost of additional tests and procedures needed to evaluate or treat the patients condition. With medical insurance there is usually a co-pay and the patient is responsible for any charges the insurance company can't pay. When an Eye Doctor establishes their prices for tests and procedures the full amount must be paid. It is illegal and considered insurance fraud for the Eye Doctor to not ask the patient to pay the residual balance their insurance does not pay. This is why pricing these tests and procedures is so difficult. Each insurance company pays a different amount for each test. We want to price these tests high enough to be fully compensated by the insurance company, but not so high as to overcharge our patients. It is difficult to balance the two. Eye insurance covers most fees from a general eye exam and portion of a patients eye glasses or contacts. Medical insurance covers most fees from eye exams with a medical diagnosis and most of the cost for additional tests and procedures related to the medical finding. It is important to remember that there usually is some cost out of pocket for the patient even with utilizing the insurance with a co-pay or residual balance. A residual balance is usually due to the insurance company not paying the full amount. Also, it is illegal and insurance fraud for your Eye Doctor not to charge you the residual balance. When you receive a bill from your Eye Doctor it is a result of your insurance company not paying as much as the average insurance company would and your Eye Doctor completing their legal obligation to charging your insurance company. Patients have the right to be upset with a bill, but patients should know that the insurance company (not the Eye Doctor) is the reason for the residual balance.