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Is your insurance out to get you?

Insurance is a BIG topic; before we start you’ll want to know that it Tis the Season to use your benefits, because you could miss out on them entirely if you wait past the end of the year!  Today we will attempt a quick explanation of how insurance works and what you need to know that they don’t want you to.

  1.  First, there are two different types of insurance accepted by medical eye care professionals: wellness eye exams are billed to vision plans and medical eye exams and ordered tests are billed to medical insurance plans.  So what constitutes a wellness visit versus a medical eye exam?  Simply put it’s the reason for visit: if you have been told you need a dilated eye exam or follow up exam by a medical professional (an eye doctor, primary care physician, endocrinologist, cardiologist…) or if you are experiencing an eye health issue (red, irritated, dry, or painful eyes), it is a medical office visit.   Systemic diagnoses like hypertension, diabetes, and certain autoimmune disorders indicate an annual medical eye exam with dilation.  If a medical dilation is indicated, the exam is covered by medical insurance (your cost is that of the specialty copay on your medical insurance), and refraction is offered as a separate service at the time of the office visit.  Wellness exams are often referred to as routine by vision plans because there is not a medical indication for dilation; the exam copay is listed among the benefits and a refraction is frequently bundled with the eye exam.
  2. Wellness visit requirements vary in definition based on state laws.  Illinois’ definition of a comprehensive eye exam can be found within the Illinois Optometric Practice Act online at  This does not often correspond with the coverage defined by vision insurance.  The components of the vision plan are negotiated between the insurance company and the employer or individual policy holder.  The agreement between the doctor’s office and the insurance company is entirely unrelated to the benefits afforded the insured.  Most people don’t know or understand their coverage, so at 4Sight iCare we review the insurance benefits before the exam and highlight features you may want to use as seen in this sample excerpt:Benefits ExplainedYou can see that this patient’s individual benefits entitle him/her to an exam at a specific copayment every year plus certain “material” (glasses or contacts) benefits.  What you may not know is how to read the different material benefit possibilities.  This very real example shows a contact lens services and material benefit of $130 if contact lenses are also purchased which goes down to $60 if not.  Frame allowance is $130 before adding the lenses and the $100 basic lenses are given at a $25 copay.  Add the reduced copay for treatments and upgrades along with covered services and it all could add up to the insurance discounting the patient’s cost on glasses by several hundreds of dollars.  This is why we recommend use of benefits to maximize your coverage: why save $70 when you could save over $300.  It also entitles the policy holder for additional “Value-Added” benefits like 30% off any second complete pair of glasses including non-prescription sunglasses and $39 retinal photos to enhance the level of preventative care.

Knowledge is power, and knowing which insurance to use and what benefits it will provide is always important to policy-holders, and 4Sight iCare believes in educating patients on every aspect of their care including the benefits and fees.  Without this assistance in reading the policy, the only winners are the insurance.  That’s what they are counting on, so when is the last time you read your benefits?