Insurance & Billing

What is a Routine Eye Exam?

A routine eye exam is defined by insurance companies as an office visit for the purpose of checking vision, screening for eye disease, and/or updating eyeglass or contact lens prescriptions. Routine eye exams produce a final diagnosis, like nearsightedness, farsightedness or astigmatism.

What is a Medical Eye Exam?

A medical exam is defined as a complaint by the patient or a diagnosis by the doctor that indicates a disorder of the eye other than the conditions that can be corrected by glasses. This includes things like eye burning or irritation, dry eye syndrome, cataracts, macular degeneration, glaucoma and diabetes.

Vision Plan:

Vision insurance plans provide coverage for routine exams, glasses and contact lenses, or provide a discount on your doctor’s fees. A routine eye exam is billed to your vision insurance plan. By law, Medicare does not pay for routine vision exams.

Refraction Fees:

A refraction is the part of an office visit that determines your eyeglass prescription. It typically involves questions like, “which is clearer – option one or option two” as different lens combinations are shown to you. Vision insurance policies generally cover both the eye exam and the refraction. While a refraction is typically used to determine your eye glass prescription, it’s also an important diagnostic test to help determine if vision loss or a decrease in vison is due to a refractive error (correctable with eye glasses) or medical pathology such as cataracts, macular degeneration, glaucoma and diabetes. Unfortunately, medical insurance only views this test as “routine” and will not cover it.

Refraction fee cost: $70.00

We Are Here to Help:

We understand how confusing the difference between “routine” and “medical” eye examinations can be and we’ll gladly answer any questions you may have. It’s important to remember that “routine” or “medical” has nothing to do with the steps involved in an eye exam or the type of doctor who performs the exam. A “routine” eye exam has components similar to a “medical” eye exam. Seeing an ophthalmologist (MD), doesn’t classify the exam as being medical either.

Examples of routine exams and medical exams:
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• My glasses broke and I need a new pair: ROUTINE EXAM

• I want to try contact lenses: ROUTINE EXAM

• I just want to make sure my eyes are healthy I have no other problems: ROUTINE EXAM

• It feels like something is in my eye: MEDICAL EXAM

• I have been told I have cataracts and want to know if I need surgery: MEDICAL EXAM

• I am a diabetic: MEDICAL

• I have blurred vision and I don’t know why: This is a little tricky and we may not know until we do a complete exam. If all you need is glasses and everything in your eye is normal then that would fall under routine exam. But if you are found to have a cataract or another medical diagnosis as the cause for your blurred vision then it will be a medical exam.

Keep These Things in Mind:

Insurance coverage doesn’t mean payment. Many health plans have copayments and deductibles that must be met before your insurance will pay any amount towards your bill.

Check with your insurance carrier prior to your office visit to make sure you have vision benefits (and what they are), to confirm that our doctors are classified as providers in your plan, and to determine if refractions are covered under your plan.

Ophthalmologists typically do not accept routine vision plans. If you have both vision coverage and medical coverage and have a medical condition such as cataracts, macular degeneration, glaucoma and diabetes and wear corrective lenses, it is recommended that you have 2 appointments, one appointment with an optometrist for the vision / glasses portion of the exam and another with the ophthalmologist for the medical portion. At the Center for Eye Care and Optical we are able to accommodate both types of exams.

Ophthalmologist Vs. Optometrist

Optometrist:

Optometrists are eye care professionals who provide primary vision care ranging from sight testing and correction to the diagnosis, treatment, and management of vision changes. An optometrist is not a medical doctor. They receive a doctor of Optometry (OD) degree after completing four years of optometry school, preceded by at least three years of college. They are licensed to practice optometry which primarily involves performing eye exams and vision tests, prescribing and dispensing corrective lenses, detecting certain eye abnormalities, and prescribing medications for certain eye diseases.

Ophthalmologist:

An ophthalmologist is a medical doctor who specializes in eye and vision care. Ophthalmologists differ from optometrists in their levels of training and in what they can diagnose and treat. As a medical doctor who has completed college and at least eight years of additional medical training, an ophthalmologist is licensed to practice medicine and surgery. An ophthalmologist diagnoses and treats all eye diseases, performs eye surgery, and checks the eyes for routine issues such as the need for eyeglasses.

While ophthalmologists are trained to care for all eye problems and conditions, some specialize in a specific area of medical or surgical eye care. This type of ophthalmologist is called a subspecialist. They usually complete one or two years of additional, more in-depth training called a fellowship in one of the main subspecialty areas such as cataracts, glaucoma, retina, cornea, or pediatrics. This added training and knowledge prepares an ophthalmologist to take care of more complex or specific conditions in certain areas of the eye or in certain groups of patients.