FAQ: Routine vs. Medical Eye Exams

Q: What are the various types of eye exams, services, and insurances?

A: Your reason for today’s eye exam, as well as the results of the exam, determine whether your insurance company will classify today’s exam as routine or medical. Types of vision and medical insurance policies vary widely, and cover different exam and service types.

There are three main categories of non-medical eye exams and services:

• A routine eye exam allows your doctor to check your vision, and screen you for eye disease or other eye-related conditions.
• A refraction may be done while you are here for a routine eye exam. This service determines your eyeglass prescription. This is its own service and is charged separately.
• A contact lens exam includes extra screenings and evaluation to determine if you are/remain a good candidate for wearing contact lenses. This is its own exam type and is charged separately.

A medical eye exam or office visit is related to the diagnosis, management, or treatment of medical conditions related to the eye. This type of exam also applies if we must communicate or coordinate with another physician regarding your exam findings or ongoing care.  Examples may include treatment for a new problem, follow-up care for an existing problem, examining the structure of the eye, certain types of diagnostic testing, etc.

Vision insurance typically covers routine vision care, eye health screenings for people without known eye disease, and refractions. These plans may also provide coverage for or discounts on eyeglasses and/or contact lenses.

Medical insurance may provide coverage when medical or eye conditions or disease are present. Examples may include diabetes, infections, dry eyes, cataracts, glaucoma, etc. Some medical insurance plans have vision riders. Please contact your insurance company directly about this benefit.

Q: How is my exam type determined?

A: It’s important to know that insurance companies (not our practice) create the definitions for exam types and services. They also determine how these exam types and services are covered by insurance plans. Not all exam types and services are covered by all insurance plans. Please contact your insurance company/ies directly with questions about your coverage or benefits.

Q: I’m here for my annual eye exam. Why do you need my medical insurance?

A: We often do not know if the exam will be routine or medical until we discuss any symptoms you may be experiencing and run tests accordingly. This means that the type of eye exam may change during the exam, depending on what your doctor finds.

Q: What happens if the doctor has a medical finding during my eye exam?

A: A claim will be filed with your medical insurance carrier for those findings, and any co-pays and deductibles for that insurance will apply. Certain non-medical services from your visit may still be coordinated with your vision insurance plan, depending on your plan details.

Q: What if you aren’t an in-network provider for my insurance?

A: We are in-network with many major vision and medical insurance carriers, which means that we are able to file claims on your behalf as a courtesy to you. If we are unable to file a claim for you, we will provide you with an itemized receipt so you can submit for reimbursement. To help us assist you, please provide our team with both your vision and medical insurance details.