If you’re having eye problems, you may wonder, is an ophthalmologist covered by my medical insurance or do I need vision insurance? In short, most ophthalmologists accept both medical and vision insurance, depending on the type of services you need. Vision insurance covers your optical needs, such as annual eye exams, eyeglasses, and contact lenses. However, it does not cover any eye services that are considered “medical”. Medical insurance will pay for medically necessary services. So, if you have an eye disease or health problem you can usually use your health insurance for that treatment. Below we’ll look at common eye issues, and what each insurance will cover.
What Is an Ophthalmologist?
An ophthalmologist is a doctor who is an expert in eye care. They are different from optometrists because they are doctors who have spent at least 12 years in school to get their license as an ophthalmologist MD. Ophthalmologists are trained to perform eye surgeries and treat eye disease as well as vision problems. They also train to do vision tests and write prescriptions for eyeglasses and contact lenses. The kind of care you get depends on why you’re going to the ophthalmologist in the first place.
An ophthalmologist can give you glasses or contacts to help you see better, as well as treat cataracts, diabetic eye problems, macular degeneration, and other eye problems. If you’re still wondering, “Are ophthalmologists covered by medical insurance?” you can rest assured that they are. You might see an ophthalmologist for things like macular degeneration or glaucoma, which are both common eye diseases. But if you have a problem with one or both of your eyes, that is the most important reason to go. Some of the most common problems with the eyes are:
Sudden Vision Changes
Some normal changes in vision are caused by genes or getting older. Changes like sudden blurriness or a change in the floaters in your eyes can mean that something serious is going on with your eyes that an optometrist can’t help with.
Double Vision
If you have double vision, it could mean that your nerves are damaged or that the issue may be residing in your brain. An ophthalmologist can look into the problem and find out what’s going on.
Eye Infections
When an eye infection gets worse, it can sometimes make it hard for you to see. The ophthalmologist can figure out what’s wrong and give you the right treatment so that an infection doesn’t hurt your eyes.
Other Eye Specialists
As we’ve already talked about, an ophthalmologist is a doctor who is licensed to treat and operate on the eye. You should always see an ophthalmologist if you have a serious eye problem or if you hurt your eye physically. An optometrist is not a medical doctor. Instead, he or she is a specialist who takes care of the eyes by doing things like testing and correcting vision, as well as treating and managing changes in vision. Most health insurance plans don’t pay for this kind of vision test, but a vision plan might. An optician is a trained person who checks and fits eyeglasses and contact lenses, usually based on what an ophthalmologist or optometrist tells them to do. A vision plan may also cover visits to the eye doctor or optician.
Common Eye Conditions
Proper eye care is important if you want to keep your eyes healthy and keep your eyesight. It’s important to know the most common eye diseases so you’ll notice if your eyes or vision change because of an injury,illness, or just aging. Most eye problems are easier to treat if they are caught early. This is one of the reasons why it’s so important to get an eye exam every year. Below are a few of the most common eye problems.
Vision Impairment
The CDC says that refractive errors are the main cause of eye problems in the U.S. Refractive errors in your eyes cause your vision to be blurry. These errors include astigmatism (distorted vision), myopia (near-sightedness), hyperopia (far-sightedness), and presbyopia (can’t focus on close objects, usually in people 40 and older). These kinds of vision problems can often be fixed with eyeglasses or contact lenses, and sometimes they can be fixed with surgery, like LASIK.
Cataracts
Cataracts, which cloud your eye’s lens are another leading cause of vision loss in the U.S. At first, stronger lighting and eyeglasses can help with cataracts, but most people end up needing surgery. Which can be quite safe and very successful depending on your situation.
Glaucoma
Glaucoma is an eye disease that damages the optic nerve and can lead to either partial or complete blindness. It is usually treated with eye drops, pills, or traditional or laser surgery. The goal with treatment is to keep glaucoma from taking your vision completely.
Macular degeneration
Macular degeneration, which causes blurred central vision, can happen in people over 40. Central vision is needed for daily tasks such as driving or reading so age-related macular degeneration can have a serious impact on your life. There is unfortunately no cure for age-related macular degeneration, but you can. The best steps are exercise, quitting smoking, and eating lots of vegetables.
Diabetic Retinopathy
Diabetic retinopathy can be treated by keeping a person’s blood sugar, blood pressure, and lipid problems under control. An annual eye exam is very important for people with diabetes, and most health insurance plans cover it.
Conjunctivitis
Conjunctivitis is a very common, but not always dangerous, eye problem. Also called “pink eye,” conjunctivitis is an infection or inflammation of the conjunctiva. It can happen to one or both eyes. It can also spread very easily. Conjunctivitis isn’t a very serious eye disease, but if it isn’t treated properly, it can turn into something worse. Depending on what’s causing it (allergy, virus, bacteria, etc.), the treatment is usually topical antibiotics or fake tears.
Amblyopia
This is one of the most common problems kids have with their eyesight. Amblyopia, which is also called “lazy eye” is when the eye and brain don’t coordinate well. One eye gets more attention from the brain than the other. This means that one eye is not being used normally. Amblyopia can lead to blindness if it isn’t taken care of properly when the child is young. But putting an eye patch over the healthy eye, which makes the child use the “lazy” eye, is often a good way to treat the problem. Also, corrective eyeglasses or contact lenses could be part of the treatment.
Strabismus
This is another common eye disease that affects children. Strabismus makes the eyes cross in or turn out. If it isn’t treated, it can also cause blindness. To stop this eye disease from getting worse, treatment should start as soon as possible, sometimes even when the child is only a week old. Also, corrective eyeglasses or contact lenses may be used.
Medical vs Vision Insurance
The main difference between medical insurance and vision insurance is how the treatment you’re getting is classified. When you look at what insurance covers during an ophthalmologist visit, you’ll find that it’s your health insurance. Your vision insurance covers an optometrist visit although it may also cover some services from an ophthalmologist. For example, you go to an eye doctor for a regular eye exam. The optometrist will take your group vision insurance for the visit and any other services you need that are covered by the policy. If the optometrist finds something wrong with your eyes that needs medical care, they will send you to an ophthalmologist. The ophthalmologist will treat the problem. Here’s how each insurance type pays for eye care:
Medical Insurance
When you have medical problems with your eyesight, you need the help of an ophthalmologist to treat and fix them. These are medical problems because you need a doctor to treat them and give you medicine, but not always to give you glasses or other tools to help you see better. Some common medical problems that your doctor can bill your insurance are:
Comprehensive eye exams with dilation (but not the part of the exam that tests your vision, called refraction)
Eye infections
Diabetes eye exams
Monitoring cataracts
Exams if you take medicine with possible side effects on your eyes, such as steroid medicines and arthritis medications
Managing and treating macular degeneration or glaucoma
Emergency appointments due to loss of vision
Under the Affordable Care Act (ACA, also called “Obamacare”), all qualified health plans must cover many eye diseases, such as glaucoma, cataracts, amblyopia, strabismus, diabetic retinopathy, and age-related macular degeneration. All of these are medical problems that your major medical insurance plan will cover. Also, Obamacare-qualified health plans must cover pediatric vision care for all patients under 19 years old, which includes an annual eye exam and, if needed, eyeglasses.
Vision Insurance
Under Obamacare, the vast majority of qualified health plans for adults do not cover eye care. This means that refractive errors or mild but common eye diseases like conjunctivitis may not be covered by your major medical insurance plan. So, what is vision insurance if some types of eye care are covered by medical insurance? Vision insurance pays for eye exams, corrective lenses, eyeglass frames, contacts, and discounts on LASIK, special coatings for lenses, and progressive lenses.
EZ Has You Covered
Regular eye exams are important for keeping your eyes healthy and keeping your eyesight in good shape,even if you’re one of the few people in the U.S. who doesn’t wear glasses or contacts. Your optometrist will check for certain problems every time you go in. Even though a lot of employers offer vision insurance, some don’t. You can find a vision plan that will cost you a lot less per year than paying out of pocket for eye care. Eye insurance is worth the money just because of this. To get started, just type your zip code into the box below or call 877-670-3557 to talk to one of our licensed agents.
With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.
