Medical vs Vision Insurance? What's the Difference?

At Sunshine Optometry, our team receives this question every single day and we want to help our patients understand the difference.

The topic of insurance has always been a confusing one, especially in the world of eye care.  We accept 2 types of insurance, medical and vision.  According to the Affordable Care Act, all Americans must have medical insurance. Your health insurance may be provided by your employer, or you may purchase this insurance yourself.  You may or not have vision insurance in addition to your medical insurance. 

Vision Insurance

Vision insurance is one of the most misunderstood benefits of all health-related coverage. Some insurance companies do a better job of educating their clients than others. At times insurance companies’ “customer service” departments overstate benefits (and minimize or even ignore specific limits and restrictions) that can create an adversarial relationship between the patient and the doctor’s office. We would like to avoid these misconceptions, and we hope that the following will help you better understand how vision coverage works.

Vision insurance is actually a vision benefit.  It is designed to pay toward "routine" comprehensive eye examinations.  A "routine" eye examination checks for, but finds no medical problems.  The refraction (determination of the eye's prescription) is included, and since there are no medical problems, there is no discussion of problems or follow-up needed.  Most vision insurance plans do not pay toward the contact lens portion of the examination, but may offer a discount on these services.  Vision insurance plans often pay a portion of (or offer a discount on) eyeglasses or contact lenses. 

Most vision plans to do not cover ANY medical testing, diagnosis, consultation or treatment. Vision  insurance  covers  ONLY  routine  eye  exams  for  purchasing  glasses  or  fitting  and  purchasing  contact lenses. Regardless of your vision insurance, most plans do not cover 100% of expenses, and thus you should expect some out-of-pocket costs. There may be co-pays, deductibles or a percentage of costs that you will pay out-of-pocket as required by your insurance policy. As with most doctors, at Sunshine Optometry the patient’s portion must be paid before materials (glasses or contacts lens) can be ordered. And all co-pays are due at the time services are rendered.

Medical Insurance

Medical insurance pays toward eye care visits that are medical in nature.  An emergency visit, or one focused on a specific eye problem, would be submitted to medical insurance.  Some examples of a medical visit are: eye infection, floaters, eyelids styes, dry eyes, glaucoma treatment, loss of vision caused by a medical condition of the eye, etc.

Medical insurance may also pay toward a comprehensive examination if there is a medical reason for it (such a s diabetes, cataracts, or any of the previously listed reasons).  If there is a medical diagnosis, we are required to submit the examination to the medical, not vision, insurance.  Believe it or not, a comprehensive examination that is medical in nature does not include the refraction.  Nearsightedness, farsightedness, astigmatism, and the need for reading glasses are not considered a medical diagnosis.  Medical insurance plans will deny this portion of the examination.  If you have both medical and vision insurance plans, our office will coordinate the benefits to minimize your out-of-pocket costs.

Understanding Your Vision Benefits

Let’s face it, insurance can be confusing. This is particularly true when an individual has both medical and vision coverage. Understanding your insurance PRIOR to any service can help you avoid confusion and frustration. 

Still confused? Watch this video:

In Summary

Although our staff members are very knowledgeable about insurance plans, remember that it is not the doctor’s or staff’s responsibility to know the details of your individual plan. It is to your benefit to be aware of possible deductibles and co-pays that are part of your plan. Your insurance plan may cover routine vision care, but if your deductible has not yet been met, you will still have to pay for the service until your deductible is met.

Your insurance is a contract between you, your employer and the insurance company; not with the doctor.

We encourage you to speak with your insurance company PRIOR to your appointment about your plans specific details. Then, as always, feel free to ask us questions about how they will apply to your upcoming visit. We will do everything we can to help you better understand your policy, but the more knowledge you have about how it works ahead of time, the less frustrating it will be for you at the time of the exam.