Does Medical Insurance Cover Eye Exams?

Buying insurance to maintain your health raises all kinds of questions. One of the most frequent queries is: Does medical insurance cover eye exams? It’s not uncommon to purchase health insurance and not understand what is covered, especially for your eyes. But with a little insight, you can find the right vision care coverage for your needs.

Does Medical Insurance Cover Eye Exams? 

Whether medical or Vision Insurance is billed for your eye care depends on how your doctor visit is classified: routine or medical. The insurance that covers your eye exam depends on the reason for scheduling an exam and the outcome of the consultation.

Your doctor can change an exam initially scheduled as routine to medical if an eye health problem is discovered. In that case, the exam may be billed to your medical insurance carrier, including any follow-up visits to diagnose and treat the health problem. Ensure you’re aware of your copay and deductible, for your medical insurance. 

Routine Eye Exam

A routine eye exam is your annual visit to the eye doctor to diagnose or treat nonmedical eye issues or to update your glasses or contacts. This includes a diagnosis for vision errors like farsightedness, nearsightedness and astigmatism.

Your doctor, who can be an optometrist or ophthalmologist, will check your vision, screen for eye diseases and write a new prescription for glasses, if necessary. Your  Vision Insurance plan covers your annual routine exam, including the cost of corrective eyewear or a discount. Medicare doesn’t cover routine eye exams.

Medical Eye Exam

When you go in for a medical eye exam, your doctor generally wants to diagnose or treat an eye disease or eye health condition, such as cataracts, conjunctivitis (pink eye), glaucoma or macular degeneration. Your medical insurance may cover a medical eye exam.

Your eye exam can get classified and billed as medical in several ways. For example, if you made an appointment to address new symptoms or complaints, such as burning, itching or stinging, or you’re making a follow-up visit to treat an existing condition, the appointment would fall under medical. 

Similarly, if your routine eye exam uncovered a medical condition, the visit is then medical. You may schedule a routine exam complaining of blurry vision, for instance, which the doctor finds unable to be corrected with glasses or contacts.

Medical eye exams are important because several eye conditions can be treated and corrected if caught early, but often have no noticeable symptoms. Here are the steps of a typical medical eye exam:

• Initial Assessment: Asks questions about eye health, medical and family history
• Visual Acuity Test: Uses the Snellen eye chart, the one with the letters on the wall
• Refraction Assessment: Tests for proper corrective lenses
• Eye Movement and Alignment Test: Checks how your eyes work together
• Pressure Test: Gauges eye pressure, which can be a sign of glaucoma
• Retinal Examination: Uses pupil dilation to examine the retina and optic nerve for any issues
• Color Test: Assesses any difficulty distinguishing colors
• Visual Field Test: Checks your peripheral vision
• Slit-Lamp Examination: Looks at the front and back of your eye

If you have healthy eyes, ophthalmologists recommend one medical eye exam between the ages 20 and 29, two between 30 and 39, as recommended by a doctor between 40 and 65 and every one to two years after 65.

Medical Insurance vs. Vision Insurance

Medical and Vision Insurance can help you maintain good eye health while managing your health care costs. Both types of insurance can assist in paying for eye care, whether preventive or medical.

Medical Insurance

Medical insurance can help pay for medical or health care expenses, such as doctor’s office visits, tests, treatments and procedures. It can help ease the financial burden of paying medical costs and allow you to get medical attention when needed.

To maintain your medical insurance, you pay a monthly premium to an insurer, and that insurer promises to pay for some or all of your medical expenses if you’re injured, diagnosed with a medical condition or fall ill.

For your eye care, you may wonder, “Does medical insurance cover eye exams?” Medical insurance may pay for exams of injured eyes or when eye health issues are uncovered. However, medical insurance doesn’t cover routine eye exams. Understanding what your medical insurance covers can help you avoid surprise medical expenses.

Vision Insurance

Vision insurance can offer help paying for eye care and eyewear. The expenses it can cover include routine eye exams, glasses and contacts and other vision services.

As with medical insurance, you pay a monthly premium to an insurance company for your Vision Insurance plan. In return, your insurer agrees to pay for routine vision expenses. Before purchasing your vision plan, consider asking what’s covered or not covered.

Typical benefits of a vision plan are annual routine eye exams, eyeglass frames, eyeglass lenses and contacts. Vision Insurance can help you keep your vision clear and your eyes healthy at a reduced cost.

Costs of Eye Exam With Medical Insurance

Your medical insurance likely won’t cover the cost of a comprehensive or routine eye exam without a vision rider. If your routine exam turns into a medical eye exam, your insurer may exclude elements of the exam deemed routine, such as the refraction evaluation.

The national average cost of an eye exam is $75 to $200, although Sam’s Club offers an exam for $45 and America’s Best has an exam for $50. This would be on top of your medical insurance copay, which the national average runs from $26 to $44 for primary care and specialty care, respectively.

Costs of Eye Exam With Vision Insurance

If you have a Vision Insurance plan, your insurance company may cover most or all of your annual routine eye exam costs. You may have a copay. The average copay for Vision Insurance is $10 to $40.

Compare the Best Vision Insurance for Eye Exams From Benzinga’s Top Providers

Wondering where to find Vision Insurance for eye exams? Here is a comparison of Benzinga’s top providers:

Protecting Your Health and Pocketbook With Vision Insurance

Buying Vision Insurance for eye exams is a step toward maintaining good eye health for years. Vision Insurance can also help keep health care costs in check.

Frequently Asked Questions