When Does Medical Insurance (Rather than Vision Insurance) Cover Eye Exams
The health of your eyes is closely linked to the health of the rest of your body. Conditions such as diabetes, high blood pressure, autoimmune diseases, and even brain tumors can manifest in the eyes before symptoms appear elsewhere.
Many people are surprised to learn that medical insurance (not just vision insurance) can cover eye exams when they are related to medical issues. Coverage details may vary depending on the specific plan, so it’s important to check with your insurer for information about co-pays, referrals, or specialist visits.
Conditions That Typically Qualify for Medical Coverage:
- Diabetes: Annual dilated eye exams are recommended and usually covered due to the risk of diabetic retinopathy.
- High Blood Pressure: If signs of hypertensive damage are suspected, a medical eye exam may be covered.
Autoimmune Diseases: Conditions like lupus or rheumatoid arthritis
Some autoimmune diseases and treatments like hydroxychloroquine can put patients at increased risk of eye conditions such as dry eye, scleritis, uveitis and maculopathy. In such cases, eye exams may be considered medically necessary and thus covered under medical insurance rather than vision insurance. Eye exams coverage often depends on the specific insurance plan and the medical necessity of the exam.
Amblyopia (Lazy Eye): The diagnosis and treatment of amblyopia, especially in children, is often covered as it is considered a medically necessary condition. Coverage may include eye exams, vision therapy, and corrective lenses, though specific benefits vary by provider and plan.
- Iritis: The diagnosis and treatment of iritis, including doctor visits, prescription eye drops (like corticosteroids), and any necessary follow-up care are often covered as medically necessary.
- Glaucoma: Once diagnosed or suspected, regular monitoring is considered medically necessary.
- Macular Degeneration: Medical visits for monitoring and treatment are covered.
Eye Injuries or Infections: These are acute issues that require medical attention and are typically billed to health insurance. Whether caused by accidents, trauma, or underlying health conditions, eye injuries can lead to serious complications such as vision loss, infection, or long-term disability if left untreated.
- Sudden Vision Changes, Eye Pain or Vision Loss: If you experience a sudden change or loss in your vision, such as blurred vision, flashes of light, floaters, or partial or complete vision loss, it’s important to see an eye doctor right away. These symptoms can signal serious conditions like retinal detachment, glaucoma, or even stroke, which require immediate attention to prevent permanent damage. Most medical insurance plans cover exams for these issues and treatment since the visit isn’t considered routine vision care.
Verifying Coverage with Your Medical Insurer
If your eye exam is prompted by a health concern or an existing medical condition, your visit may be billed to your medical insurance rather than your vision plan. If you have an unmet deductible, the cost of the exam will apply to your deductible, and you’ll receive a bill for the amount contracted with your insurance company. Your insurer should be able to tell you if you’ve met your deductible and/or what amount is still needed to meet that deductible.
Lakeview Clinic recommends always verifying your benefits with your insurance company. A Vision Benefit Verification Checklist is available on our website to assist you with obtaining the appropriate information from your insurance company. Coverage details vary depending on the specific plan, so it’s important to check with your insurance company for information about coverage, co-pays, referrals, or specialist visits.
The Value of an Experienced Eye Doctor
Choosing an eye doctor who prioritizes comprehensive health screening, not just vision correction, is crucial. Optometrists and ophthalmologists who are well-versed in systemic health conditions can detect early warning signs and coordinate with your primary care physician or specialists. Lakeview Clinic Optometrists can easily view information in your medical chart and communicate with your primary care physician when needed. This is an added benefit of our comprehensive care approach! In addition, your primary care doctor can easily see your eye exam chart and concerns raised by your Lakeview Optometrist.
So, while you may pay more for an eye exam at a medical clinic, consider a high-quality eye exam as an investment in not only your vision, but your overall health as well. Our team is experienced and works hard to ensure patients receive premium care at every visit.
Lakeview Clinic Optometry Team
- Dr. Bradley Ludwig, OD
- Dr. Tracy Jackson, OD
- Dr. Thomas Bryan, OD