Routine vs. Medical Eye Exams
To understand the difference, one must analyze the different types of eye exams. Even though office visits to an eye care professional are usually categorized as either "routine" or "medical," this terminology has nothing to do with the steps it takes to perform a comprehensive eye exam nor the type of doctor who performs the exam. A comprehensive "routine" vision exam often contains the same elements as a comprehensive "medical" eye exam, and seeing an ophthalmologist doesn't make the exam medical in nature.
The type of eye exam you have is determined by the reason for your visit or your chief complaint, as well as your diagnosis. Routine vision exams usually produce final diagnoses such as nearsightedness or astigmatism, while medical eye exams produce diagnoses such as "conjunctivitis." Most insurance companies focus on the reason for your visit.
Understanding Your Coverage
Insurance companies sometimes handle routine eye exams differently than medical eye exams. Your medical insurance may cover a medical eye problem, but not pay for the exam if it is a "routine" eye exam. Many vision plans provide coverage for glasses and contact lenses, or at least give you some type of discount on the doctor’s fees. Your medical insurance will pay for examinations if you have eye health problems.
Many 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 an eye exam that is for a medical eye problem. Study your policy closely, as plan coverage varies among insurance companies.
What happens if you have concerns about your eye health but you also need new glasses? Can you have your vision checked even though you have a medical eye problem? The answer, of course, is yes. However, your eye doctor may charge you a refraction fee. Insurance companies usually separate the components of an eye exam, one being the comprehensive exam and the other being the refraction. Typically, vision insurance policies usually cover both the eye exam and the refraction, while medical policies cover the exam only.
A Real-Life Example
Let's say your employer provides both types of insurance -- medical insurance as well as a separate vision plan, such as Vision Service Plan (VSP). You decide that it's time for your annual eye exam because your glasses are falling apart. So you see your eye care professional for a routine eye exam and to purchase new glasses. Your doctor’s office authorizes your benefits so you proceed with the examination. At the end of the exam, your doctor informs you that in addition to a minor prescription change, he found signs of glaucoma. You are instructed to return in one week for additional tests.
Remember that your original reason for the visit had been to have an eye exam and to purchase new glasses. Even though your doctor found signs of glaucoma at the end of the examination, this visit would be covered under your "vision plan" because the main reason for the visit was to get your vision checked for new glasses. But, because at the end of that exam you are considered a potential glaucoma patient, your medical insurance will cover the additional tests and office visits related to the 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. This serves as a medical diagnosis with your reason for the visit being "glaucoma suspect."