Vision Coverage

   Most insurance plans in this area separate eye exams for "refractive" diagnoses from general medical coverage, similar to dental coverage plans. If the company offers vision examination and glasses as a benefit, it may be through a limited number of providers who have been contracted separately for this particular service. I may be listed as a "provider," but this may apply only for "medical" diagnoses such as conjunctivitis, cataract, retinal hemorrhage, etc. Some plans even consider strabismus and amblyopia as "vision" diagnoses, restricting your options for having children evaluated by a pediatric ophthalmologist for these clearly medical problems.

   This is a frequent source of confusion for patients and referring doctors. If a child performs sub-optimally for a vision screening test, there may be no problem, a refractive problem, or a medical problem such as strabismus or amblyopia. I won't know the diagnosis until the patient is examined. Once the problem is identified, a diagnostic coding number is generated for insurance processing. If the company's computers are programmed to separate "vision" diagnoses, typically hyperopia (367.0), myopia (367.1), and astigmatism (367.21), from "medical" diagnoses and if the plan specifies that these diagnoses be covered only by a limited number of selected sub-contracted examiners, a claim from my office will be denied - and you will be responsible for the charges.

   We try very hard to help make you or your referring physician's office aware of these issues when the appointment is scheduled - but we cannot know the coverage details of every insurance company. Plan structures and computer coding edit programs are changed periodically, further complicating matters. To minimize confusion, we strongly encourage you to review the details of your insurance plan prior to finalizing your appointment. If the details are not specified adequately in the materials provided with the policy, contact the company's Customer Support representatives (usually specified by an 800 number on the back of the insurance card). Many insurance companies have helpful Web pages, some of which are referenced on the preceding page.

   Many of our patients and parents elect to bypass limited vision coverage plans and pay out-of-pocket to be seen by a pediatric ophthalmologist, acknowledging the potential benefits of additional medical training and experience. We welcome this decision but have found that it is generally more comfortably accepted if one has already investigated insurance plan limitations before arriving for a scheduled appointment.