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"Routine"
vs. "Medical" Examinations Most health insurances divide eye
examinations into two categories:
- Routine Eye Examinations
- This is a complete eye examination which is covered once every 1 to
3 years, depending on the insurance.
The purpose of this examination is to establish that the eyes and visual
system are healthy, and a glasses or contact lens prescription may be
determined. "Refraction Fees" and contact lens fitting
fees are often considered separate services and have separate charges.-
- In "routine"
examinations, there is usually no other ocular diagnosis or problem except
those relating to a glasses prescription (nearsighted, farsighted,
etc.)
Vision Plans and some Medical Insurance Plans offer coverage for Routine
Eye Examinations. It is the patient's responsibility to know their
specific benefits.
Note that Medicare does not cover "routine" eye examinations, but in
many cases a medical diagnosis can be used (see below).
-
- Medical Eye Examination
- A "Medical Eye Examination" is performed
when there is either a medical diagnosis of the eyes or visual system
themselves (such cataract, glaucoma, retinal problems, conjunctivitis,
dry eye, etc.), or there is an overall medical diagnosis which might
affect the eyes (such diabetes, hypertension, etc.).
Furthermore, an eye examination can be considered "medical" if it is in
follow-up of a previously diagnosed condition.
-
- Medical Eye Examinations may require a
written insurance authorization from a "gate keeper" medical physician
prior to the eye examination. A glasses or contact lens prescription may
be obtained during this examination as well, although this considered a
separate service with a separate fee.
- What if I have both a Vision
Plan and Medical Insurance?
- In this case, the Vision Plan can be
used if the examination is intended to be a Routine Eye Examination as
described above. However, if there is a chance that the
examination may be medical, it is better to obtain an referral /
authorization, if required by your insurance company, in advance.
Note that eye examinations performed because of a medical condition such
as diabetes should always be considered medical, because services may be
required (such as fundus photography) that fall outside of the scope of
a routine eye examination.
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