Does Medical Insurance Cover Eye Exams?

Does medical insurance cover eye exams? If you're wondering, you're not the first one. The specifics of medical insurance can be confusing — vision coverage is no exception. Insurance providers categorize visits to an eye doctor as either medical or routine. And because vision insurance is supplemental to standard health insurance, it can be difficult to understand which benefits are included and which you need to purchase.

Check out our guide to learn the difference between medical and routine eye exams, the specifics of different eye doctors and how you can find the best vision insurance coverage.

Medical Insurance and Eye Exams

Your reason for visiting an eye specialist and the outcome of your examination directs whether your insurance provider will classify the eye exam as medical or routine.

Based on the policy, medical insurance might pay for the treatment of a medical eye problem but not a routine eye exam. If you have medical insurance, a separate rider to cover routine eye exams or dental insurance is common.

Medical Eye Exams vs Routine Eye Exam

Some medical insurance may pay for a single routine eye exam every 2 years in addition to eye exams for a medical eye problem. Copays for both exams also differ.  

Read on to clarify the difference between medical and routine eye exams and how insurance covers each. This will help you determine if your medical insurance covers eye exams.

Routine Eye Exam

A routine eye exam is quite straightforward – it typically takes place once a year and may include screening for eye diseases and updates for your contact lens or eye glass prescriptions. Routine eye exams provide a final diagnosis like farsightedness, nearsightedness or astigmatism.

Your vision insurance policy will cover 1 routine eye exam annually. Even if your carrier doesn’t cover your actual exam, it may provide some discounts when you see an eye doctor. Look into the fine print of your specific plan. You’ll pay out of the pocket for this eye exam if you don’t have vision coverage at all. By law, Medicare won’t pay for your routine vision exams.

Medical Eye Exam

Someday you may walk in for your routine eye exam and discover that something’s wrong beyond your eyesight. If you face a diagnosis of something like glaucoma or conjunctivitis, your exam officially shifts to a medical eye exam.

You may have the suspicion that something’s wrong with your eyes and book yourself into an eye exam. If the purpose of your visit is to assess your pain or other symptoms, or to monitor an existing medical condition, it is considered a medical eye exam.

An examination for medical eye care, evaluation of an eye complaint or follow up on an existing medical condition are usually billed to your medical insurance provider instead of your vision insurance plan. This implies that medical eye exams may receive better coverage through insurance compared to routine eye exams.

The difference between the 2 eye exams may seem slight, but it’s crucial to understand them – it may impact your insurance.

If you’ve never experienced an eye exam, here’s a breakdown of what you can expect when you schedule an appointment:

• Introductions: New patients must complete an eye and medical history form and mention any symptoms. The eye specialist will assess and address any risks of eye disease, vision problems or concerns with other medical conditions.
• The Snellen chart: This is the chart that contains letter-filled rows with varying sizes. It’s used to assess your visual sharpness. The eye doctor will want to know the smallest row you can read.
• Refraction: Your eye doctor uses a retinoscope or computerized vision-testing equipment. The doctor will also shine some light into your eyes to get a read on your vision and estimate the prescription strength. Then comes a fine-tuning process – the doctor uses many different lenses in front of your eyes to check which allows you to see better.
• Left then right eye: The doctor will use an occlude to block vision in 1 eye followed by the other to see how each eye performs on its own.
• Color time: This test involves looking at special cards with colored dots that form numbers. Your color vision is perfect if you can read the numbers. If your color vision is poor, you may struggle to see the number or it may be entirely invisible.
• The puff test: This is a common test for glaucoma that measures the fluid pressure in your eyes.
• A closer look: Your eye doctor may dilate your pupils to take a closer look for any eye and health conditions.
• Zooming in: A biomicroscope or slit lamp lets your eye doctor get a magnified view of the inside and front of your eyes. It helps the doctor check off conditions like muscular degeneration, cataracts and diabetic retinopathy.

The examination is simple from start to finish. Why not make an appointment with your eye doctor and have your eyes tested?

Optometrist vs. Ophthalmologist

You flip through your calendar and realize it’s time to pay an eye doctor a visit. It’s easy to set up your appointment, but determining the correct eye professional is puzzling. To clear the confusion, let’s break down the difference between an optometrist and ophthalmologist.

An optometrist is the most common stop for comprehensive eye and vision care. This professional provides primary vision care, including sight testing and correction, diagnosis and treatment. Optometrists are also crucial in the detection and management of certain diseases in the eye like muscular degeneration and diabetes. These eye doctors may also rehabilitate conditions like lazy eyes.

An optometrist must complete 4 years in optometry school to earn a doctor of optometry degree. You can identify optometrists by the letters “OD” behind their name.  

An ophthalmologist is a medical doctor who specializes in all every aspect of eye care, including the diagnosis, treatment and surgery of eye diseases and disorders. You’ll usually have your primary care with an optometrist and be directed to an ophthalmologist for any special diagnoses or emergent care needed.

To identify an ophthalmologist, look for the letters “MD” or “DO” behind their name. It signifies a Doctor of Medicine or Doctor of Osteopathy.

Each type of eye care professional brings a different aspect of care. Since an ophthalmologist is technically a medical doctor, a visit will fall under your medical plan. Your vision insurance will cover basic eye exams but won’t necessarily cover visits to an ophthalmologist.

Cost of Eye Exam Without Vision Insurance

Without vision insurance, the out-of-pocket cost of an eye exam may be beyond your budget. Here’s how much you can expect to pay for your eye exams without vision insurance in a few states.

You can expect to pay more during your initial eye exam compared to subsequent visits. Use the VSP online calculator for a better idea on how much an eye exam will cost out of the pocket in your state.

Get Vision Exams to Stay Healthy

Now that you know if medical insurance covers eye exams, it's important to make sure you stay up on your health. Regular eye exams are essential, even if your vision is perfect. An eye exam can detect diseases like diabetes and high blood pressure, and comprehensive vision coverage means you can keep your eye health and costs in check.

Use the VSP Find a Doctor search to choose a doctor in its network today.  

**Savings are based on national averages on comprehensive eye exams and most commonly purchased frame brands and may vary by VSP plan and purchase selection, average savings determined after benefits are applied.

Frequently Asked Questions