The specifics of medical insurance can be confusing, and vision coverage is no exception. Insurance companies usually categorize visits to your eye doctor as either "routine" or "medical”. This has little to do with the steps it takes to perform a full eye exam. A "routine" vision exam often contains the same elements as a "medical" eye exam. Also, the type of eye doctor you see does not determine if the examination is termed routine or medical, and either an optometrist or an ophthalmologist can perform the exam.
The reason for being seen and the results of the examination often determine whether insurance will classify the exam as routine or medical. The difference is determined by the reason for the visit, such as symptoms and complaints, and also the patient’s diagnosis. Insurance companies often look at both when determining payment. The routine vision exam usually produces a final diagnosis, such as “nearsightedness” or “astigmatism”, while the medical eye exam produces a diagnosis such as "conjunctivitis" or "cataract."
Depending on your policy, your medical insurance may cover a medical eye problem, but not pay for the exam if it is a "routine" eye exam. Other policies contain vision plans that provide coverage for glasses and contact lenses or at least give you some type of discount on the doctor’s usual and customary fees. Many times, people with medical insurance have a separate rider policy to cover routine eye exams. To complicate matters more, some medical insurance will cover one routine eye exam every two years in addition to covering eye exams that are for a medical eye problem. And the co-pay for each type of exam may be different!
Here is an example of how both may work in real life:
You’ve decide that it is time for an eye exam because your glasses are falling apart, and you remember that you chose a health plan with routine vision coverage beacause you and your family members wear glasses. You first schedule a visit with one of our doctors, then arrive at your appointment where our office authorizes your benefits, and we proceed with the examination. At the end of the exam, your doctor informs you that in addition to a minor prescription change, the examination reveals signs that you may have glaucoma. He or she instructs you to return in one week for additional tests. Because at the end of that exam you are considered a potential glaucoma patient, your medical insurance may cover the exam and additional tests for a medical diagnosis of "glaucoma suspect." When time comes for your examination next year, it is possible that you could use your medical insurance to cover your examination, because this year it was determined that you could be at risk for developing glaucoma. You also may have expected a copay of $20 that your plan requires for a routine eye exam, but end up paying a bit more or even less, if your copay for a medical exam is different.
It is to your benefit to be aware of possible deductibles and co-pays that are a part of your plan. Your insurance plan may cover routine vision care, but you might end up paying for it anyway if your deductible has not yet been met.