Health or Vision Insurance?

The eye care medical field has an unusual split between two different types of insurance for covering eye issues: health insurance and vision insurance. Not all patients have both.

In most cases, your health insurance is used to cover medical and surgical eye problems but not routine exams or the cost of contacts or glasses. Those things are often covered by separate vision insurance.

Why the difference? Originally, health insurance was created to take care of health “problems” and wasn’t designed to cover “routine,” “screening,” or “wellness” exams.

Since health insurance wasn’t going to cover “routine” eye exams, the vision insurance industry arose to help insure/cover those routine exams as well as the costs of glasses and/or contacts if they were needed.

That dichotomy now often causes great confusion when you make an appointment at your eye doctor. When making your appointment, the office is going to need to know which insurance, if you have both, you are going to be using for this particular visit.

Why does the office need to know in advance which insurance you are using?

The main reason is that the rules and sometimes the providers are different for each insurance plan. The vision plans often require the office to check on your availability for coverage and get pre-authorization for the visit BEFORE you get to the office. There are also differences in which providers within an office are in network for the insurance. For example, in some practices the optometrists might be in all the vision plans but the ophthalmologists might not in those plans. If you make an appointment with one of the ophthalmologists and tell the office you are using your health insurance you can’t change your mind the day of the appointment and use your vision insurance instead.

There are also differences in what the insurance will cover as a reason for the exam.  Vision insurance typically covers ONLY routine exams. Those are exams during which you are coming in specifically to get your vision, glasses and/or contact lens prescription checked and get an overall eye health screening.  That means you CAN’T have a medical complaint about your eyes you want the doctor to deal with. Eyes itchy? Need to use your medical/health insurance.  Dry eyes? Need to use your medical/health insurance.  Have a cataract? Glaucoma? Macular Degeneration? Need to use your medical/health insurance.

Why not just use your medical insurance all the time? That’s mostly because if you have no complaint at all your medical insurance won’t cover that visit (and “my vision is a little blurry” usually won’t cut it).  There is one other issue and that is the refraction.

A refraction is when we check to see if you need a new eyeglass or contact lens prescription. For the most part, health insurance won’t cover the fee for the refraction, which is a procedure that is separate from your eye health exam. Your vision insurance will cover the refraction but not the exam if you are having a medical problem.

Here’s the real kicker. Your health insurance will cover your medical eye problems and your vision insurance will cover your refraction, BUT you can’t use both insurances at the same visit. It has to be one or the other.  (Ridiculous right? I didn’t make the rules, just trying to abide by them.)

So, what are your choices if you have both a vision plan and health insurance? If you have a problem, you need to use your health insurance. If you want to have your eyes refracted so you can get new glasses at the same time you can either pay out of pocket for the refraction OR you can come back in for a second visit, using your vision plan to get a refraction and eye health screening exam so that the refraction gets covered. (Again - I didn’t invent these rules--I am just trying to help you navigate them.) If you don’t want to make two visits, then use your health insurance (with the appropriate complaint) and pay for the refraction and just use your vision insurance to help pay for the actual contacts or glasses you are going to buy.

If you have a question, it’s best to ask when you call the office to inquire about an appointment.

Dry Eyes or Allergies? Or Something Else?

As an eye doctor, diagnosing a red eye can be challenging. Are we dealing with an infection, allergy, inflammation or dryness?

One of the most common questions I get is, “Doc, my eyes are red, burning, itchy, and tearing. Is this dry eye or from allergies?” The short answer is it could be one, both, or neither. I’ll outline various ways these conditions present clinically and the treatments for them.

The hallmark symptom of allergy – meaning if you have this symptom you almost definitely have the condition – is itching. Red, watery, ITCHY eyes are almost invariably due to an allergen, whether environmental or medicinal. It is one of the most common ocular conditions we, as eye doctors, treat -- especially when plants are filling the air with pollen as they bloom in the Spring and then die off in the Fall.

The itching occurs because an immune cell called a mast cell releases histamine, causing the itching sensation. It can be quite unbearable for the sufferer, causing them to rub their eyes constantly, which actually increases the amount of histamine in the eye, leading to worsening of the symptoms.

Treatments may include:

  • Over-the-counter or prescription allergy drops (mostly anti-histamines or mast cell stabilizers).
  • Topical steroids (to get the inflammation under control).
  • Cool compresses applied to the eye.

Patients sometimes need to take drops every day to keep their symptoms under control.

Dry eye can have many of the same symptoms as allergic eye disease, with the eye being red and possibly watery ("My eyes are tearin--how could it be dry eyes?"). The main exceptions are that people with dry eyes tend to complain more of burning and a foreign body sensation - like there is sand or gravel in the eye - rather than itchiness.

Dry eye is a multi-faceted disease with many different causes and treatments. Treatment ranges from simple re-wetting eye drops to long-term medications (both topical and oral), as well as non-medicinal treatments such as eyelid heating treatment.

So how do we determine the difference? The first question I ask patients who complain of red, watery, uncomfortable eyes is, “What is your MAIN symptom? Itching or burning?” The answer will likely direct which course of treatment we take, and as those treatments sometimes overlap, you may have a component of both dry eye and allergy.

That is important to distinguish because many of the treatments we use for allergies - like antihistamine eye drops - can sometimes make the dryness worse. Though neither of these conditions is 100% curable (except maybe for allergy, where if you remove the allergen, you obviously won’t get symptoms!). We have many tools in our treatment arsenal to keep the symptoms at bay.

Unfortunately, dry eye and allergy aren’t the only two things that can cause your eye to have the multiple symptoms of red, watery, itchy, burning eyes. There are other problems, such as blepharitis, that can produce a similar appearance, as well as bacterial and viral infections.

So before embarking on a particular therapy, it is wise to have a good exam to help you get on the right track of improving your symptoms.

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Our doctors and staff are committed to providing thorough care with personal attention. At Eye Doctors of Madison, you will find the compassionate care of a small-town doctors' office with the knowledge of a big-city institution. It is our mission to not only treat each patient uniquely but also like family.

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