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Vision Insurance Primer

BenefitsAll

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Even when people have vision care benefits, they often do not use it. But why pay even a dollar for something you know you will not use? And why not use your vision care benefits if they can save money by diagnosing vision issues sooner rather than later?

You may not need vision care benefits on an ongoing basis, but they may come in handy from time to time. If you are considering these benefits, you should know how they work.

Click on the dark blue tab to learn more about vision insurance coverage.

There are two types of vision insurance plans:
  1. Vision Benefit Plans (also called Comprehensive Plans)
  2. Vision Discount Plans
  1. Vision Benefit Plan Features –

    • Usually separate from medical coverage
    • You or your employer pay a fixed monthly premium
    • Can be paid with pre-tax dollars if part of your employer’s “cafeteria” plan
    • Includes paid-in-full coverage for a set of benefits such as routine eye exams, discounted hardware (frames, lenses, and contact lenses), and discounts on eye surgery
    • Benefits provided at a certain frequency (e.g., every 12 to 24 months)
    • Typically includes a network of participating eye care providers
    • May have the option of seeing an out-of-network provider, with the plan paying a small percentage of the costs. You are responsible for any additional fees an out-of-network provider charges

  2. Vision Discount Plan Features –

    • May or may not be separate from medical coverage
    • You or your employer pay a fixed monthly premium, which is usually less than the premium for vision benefit plans
    • Provides discounts for eye care needs such as exams, hardware, and surgery, and you have to pay the balance at the time of service
    • Typically includes a network of participating providers who have agreed to the plan’s discounts



The primary difference between these two types of vision insurance plans is that you get coverage for a set of benefits with the vision benefits plan. For example, you pay a $10 copay for an eye exam, and the plan pays the balance. With the vision discount plan, you pay for the full exam but less than the regular price. So, instead of paying $75 for an exam, the provider who has agreed to accept a discount may charge you $55.

These two types of plans have in common that they both have a network of participating providers, and both cover specific services and products such as routine eye exams, frames, and lenses.

The confusing thing about vision insurance coverage is that it can come in many different forms. Although there are primarily two types of vision insurance plans (vision benefit plans and vision discount plans), there can be several variations of these types of plans. For example, your medical or dental plan may include a vision discount program that is not an insurance plan (also called an access/discount-only program).

These discount programs are very popular and are often part of the medical plan. They typically share the same network of participating providers as the medical plan and do not issue separate ID cards.

A vision discount program may have a separate network name from your medical plan. For example, Aetna medical plans may offer a vision discount program whose network is administered by EyeMed Vision Care. Consequently, confirming if a provider accepts your vision care program requires knowing the plan's name and network. The name of the vision program network is always included in the plan documentation. It may also be listed on the back of your medical plan ID card if part of the medical plan.

In addition to vision discount programs, there are hybrid vision programs. Hybrid programs combine an insured benefit (routine eye exam) with a discount program for other services (lenses, frames, laser surgery).

Most vision insurance plans cover routine eye exams or contact lens exams. Some plans cover one or the other type of exam, and some cover both. Check your plan documents before scheduling an exam.

Vision insurance plans do not always cover contact lens fittings as part of the exam. Fittings may require multiple measurements and readjustments to ensure a proper fit, which may mean multiple visits to the eye doctor. Review your plan documents to see if these fittings are covered as part of the eye exam.

Eyeglasses and contact lenses are the most often used vision care benefits.

Most vision insurance plans cover eyeglasses or contact lenses, but not both.

Vision insurance coverage for eyeglass lenses is usually a set benefit or discounted amount for basic lens options. Basic lens options may include ultraviolet coating, blended invisible bifocals, or photosensitive glass lenses.

These plans also include a schedule of benefits for optional lenses and coatings, such as scratch-resistant coating, high-index (thinner and lighter) lenses, or standard or premium progressive lenses. These optional lenses and treatments (also called add-ons) are expensive and can add several hundred dollars to your out-of-pocket costs.

A healthcare flexible spending account (FSA) allows you to set aside tax-free money to pay for anticipated health care expenses (medical, dental, and vision care) that are not paid for by your health insurance. If you anticipate incurring dental care expenses that exceed your dental plans maximum annual benefit allowance, you should consider enrolling in a healthcare FSA in the year you will receive the dental care services.

It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will insure that you set aside a reasonable amount in your FSA.

Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.

Change to healthcare FSA annual limit. As of the January 1, 2015 plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)

New FSA Carryover rule. As of the January 1, 2014 plan year, employers may allow participants to carry over up to $500 in unused FSA funds. This new carryover rule must be adopted by the plan--it is not automatic. Also, employers who currently have a FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
Maybe. It depends on the treatment. For example, if you had fillings started under one insurance plan and changed plans during open enrollment, your new insurance would cover any additional fillings you needed. The only time an insurance company would not continue dental coverage for work in progress is when the policy has a missing tooth clause. For example, if you had a tooth removed under one insurance plan and changed plans during open enrollment to a new plan with a missing tooth clause; the new plan would not pay to replace the tooth. The missing tooth would be considered a pre-existing condition.

Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Dual coverage is not the same as double benefits, and it does not mean that combining both plan's benefits would cover 100% of the cost of a particular dental procedure. For example, if your primary dental plan pays 50% of the cost of a crown (up to a maximum dollar amount), and your secondary plan pays 60% for a crown, you would likely receive a total benefit of 60% and would be responsible for the balance. This is because most plans have non-duplication rules that state that they will only pay the difference between what the primary carrier paid and what the secondary carrier would have paid if they were primary.

Consequently, enrolling in more than one dental plan makes sense if:
  • one plan provides benefits you need that are not provided by the other plan
  • one plan provides a greater reimbursement for dental services that you plan to use, and the percentage difference is greater than the cost of the premium of the second plan
  • enrollment is free
Unfortunately, this situation happens more often than it should... However, you are responsible for any charges incurred and not covered by the insurer if you "mistakenly" visit a non-participating dentist. Even if the dental office provided you with incorrect information... It is always the patients' responsibility to make sure that their dentist participates in their plan's network, if they want to take advantage of in-network benefits.

How to avoid this issue:

  1. Know which plan you are enrolled in and the plan's network. For example, if you are enrolled in the Delta Dental PPO Plus Premier plan, you would know by reading your plan summary that you have access to two dental networks (Delta Dental PPO and Delta Dental Premier). Both networks provide discounts and no balance billing.

    Also, a dentist may accept a different Delta Dental plan and just say "yes" if you ask if they accept Delta Dental. It is important to be specific when asking if a dentist participates in a certain plan and network

  2. Visit your plan's web site to find participating provider information online. You must still select the correct plan and, sometimes, network when using these tools.

    Remember that contracts between dentists and insurers may end at anytime; make sure the dentist is participating as of the date you receive services. Never assume that an online database of participating providers is up-to-date

  3. Call the insurer to confirm that the dentist is a participating provider and which network they participate in, so that you can get the maximum benefits from your plan

You should plan to do all of the above, not one or the other…

You can also request that the dentist accept the in-network reimbursement as payment in full, if they mistakenly informed you that they accepted your plan. Of course, they are under no obligation to do so, but if they want to keep you as a patient, they might.
Even if you did not change dental insurance plans during your annual open enrollment period, your plan's benefits may have changed. Insurers, with the approval of employers, make changes to dental benefits that are not always obvious to plan participants. Always review your dental plan information before visiting the dentist. Never assume, because you did nothing, that your dental plan benefits have not changed from year to year.
  1. Insurance companies may reduce dental care benefits through frequency limitations:
    • reducing fluoride treatments for minors from twice per year to once per year
    • replacing crowns every 10 years instead of every five years

  2. Dental insurance plan documentation may not be completely clear. For example, your benefit plan summary may state that crowns are covered, but leave for the small print that metal (silver) crowns, not porcelain (white) crowns are covered. Or the plans will pay for porcelain crowns for front teeth only. If your dental insurer only covers metal crowns, you may be responsible for paying the difference between the cost of the porcelain and metal crown. Some dental insurance policies provide benefits for the least expensive alternative treatment (LEAT), also called downgrading. With the LEAT provision, insurers may cover a percentage of a silver filling and the patient pays the difference between this amount and what the white filling cost. Some insurers may not pay anything for white fillings. Review your plan documents carefully

  3. Plan reimbursements are based on maximum allowable charges or usual and customary fees; it is almost impossible to accurately determine what the insurer will pay and what you will owe

  4. You may need more work than previously thought and the dentist may need to address these prior unknown issues while they have you in their chair
So, in addition to reviewing your plan documents, you should work with your dentist to submit a pretreatment estimate to the insurer. The insurer will determine what benefits will be covered and at what rate.

Reviewing your plan documents fully and working with your dentist and insurer, before you receive care, can reduce unexpected dental expenses.
  1. Deep cleanings (also known as scaling or root planing). Deep cleanings are needed when there is tartar beneath the gum line, separation of the gum tissue from the root of the tooth and inflammation of the gingival tissues. Deep cleanings are performed to prevent further loss of bone and gingival attachment that sometimes cannot be determined by x-rays alone. Therefore, a thorough periodontal evaluation by your dentist is required to determine the need for a deep cleaning.

    Dental insurers often use consultants to approve or deny claims for deep cleanings, and may not always have the best interests of the patient in mind.

  2. Transitional partial dentures. A dentist may provide a transitional partial denture (also known as a flipper) after removing teeth so that the patient does not have to walk around with a space in the mouth while awaiting a more permanent solution

This is when you learn just how far your dentist is willing to assist you in getting your “eligible” claims paid by the insurer. The dentist may have to appeal the denial several times before the insurer will pay the claim.
If you have dental insurance, you can prevent denial of dental care claims by following a few simple rules:
  1. Read plan documents, and not just the two-page summaries provided during the annual enrollment period. Ask for a copy of the plan's full summary plan description. These documents are often available in electronic format, making it easy to review only those sections related to your needs

  2. Review the benefits exclusions or (frequency) limitations section of your plan. This section will list which dental care services your plan will not cover, even if you want or need them, and it will state under what circumstances your plan may or may not cover other services

    For example, dental plans typically exclude coverage for cosmetic dentistry. Dental insurance companies categorize cosmetic dentistry as elective, not a necessity. The plans may also limit services for gum treatment, crowns, dentures, and implants within the first 12 months of the date your coverage starts

  3. Work with your dental care provider(s) to create a treatment plan and submit it to your insurer for a benefits review before the work is performed. Also, make sure your dentist obtained preauthorization, if required, and submitted all necessary and accurate paperwork to the insurer

  4. Make sure your dentist is willing to advocate on your behalf should a claim be denied (e.g., submit a letter of appeal or provide additional documentation).

Nearly all vision insurance plans and discount programs offer some coverage for basic frames, usually every 12 or 24 months.

Frames come with one of the most significant price markups of any consumer product. If the frames offered by your vision plan are not your style, consider shopping for reasonably priced frames online. Of course, you need to work with the provider to ensure that your lenses can fit properly into your chosen frames.

If you must have expensive lens options and frames, consider setting aside money in a healthcare flexible spending account to pay for them.

A health care flexible spending account (FSA) allows you to set aside tax-free money to pay for anticipated health care expenses (medical, dental, and vision care) not paid for by your insurance.

With a health care FSA, you have to decide before the start of the Plan Year how much you expect to incur in eligible expenses for the upcoming 12-month period. This is the amount you want to elect to contribute for the year.

Sometimes it is unclear if your vision insurance or medical plan covers a vision care visit. The determination is usually based on the reason for the visit. For example, if you are diagnosed with glaucoma, diabetes, or cataracts, you may need a medical eye exam instead of a routine eye exam. The medical eye exam is covered by your medical plan, and the routine exam by your vision plan. Also, injuries to the eyes are covered by your medical insurance.

Many retail and private optical offices offer free trial contact lens promotions if you have a contact lens exam and want to try a pair of disposable contacts. They also have periodic sales of eyeglass frames and sunglasses. These promotions and discounts can be combined with vision insurance coverage or used in lieu of purchasing vision insurance.

Also, check out local deals on exams, lenses, and frames from Amazon, Angie's List, Groupon, your local paper, etc.

It is important to get regular eye exams even if you have “perfect” vision or no known eye problems. Just like a routine medical exam, a routine eye exam can uncover an eye issue you did not know you had. But this does not mean you need to purchase separate vision insurance. Often, your medical plan will cover an annual eye exam.

However, if you have ongoing vision care needs and require regular exams, eyeglasses, or contact lenses, consider participating in a vision insurance plan or vision discount program. But keep in mind that vision care can be pricey. Never purchase more services than you need, no matter how good the deal may sound (buy two pair of glasses and get 30% off the second pair if you buy the same day). A backup pair of glasses is nice, but 30% off $1,000 designer frames is not a good deal. Shop for the lowest prices for vision hardware and services, especially frames.

A healthcare flexible spending account (FSA) allows you to set aside tax-free money to pay for anticipated health care expenses (medical, dental, and vision care) that are not paid for by your health insurance. If you anticipate incurring dental care expenses that exceed your dental plans maximum annual benefit allowance, you should consider enrolling in a healthcare FSA in the year you will receive the dental care services.

It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will insure that you set aside a reasonable amount in your FSA.

Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.

Change to healthcare FSA annual limit. As of the January 1, 2015 plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)

New FSA Carryover rule. As of the January 1, 2014 plan year, employers may allow participants to carry over up to $500 in unused FSA funds. This new carryover rule must be adopted by the plan--it is not automatic. Also, employers who currently have a FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
Maybe. It depends on the treatment. For example, if you had fillings started under one insurance plan and changed plans during open enrollment, your new insurance would cover any additional fillings you needed. The only time an insurance company would not continue dental coverage for work in progress is when the policy has a missing tooth clause. For example, if you had a tooth removed under one insurance plan and changed plans during open enrollment to a new plan with a missing tooth clause; the new plan would not pay to replace the tooth. The missing tooth would be considered a pre-existing condition.

Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Dual coverage is not the same as double benefits, and it does not mean that combining both plan's benefits would cover 100% of the cost of a particular dental procedure. For example, if your primary dental plan pays 50% of the cost of a crown (up to a maximum dollar amount), and your secondary plan pays 60% for a crown, you would likely receive a total benefit of 60% and would be responsible for the balance. This is because most plans have non-duplication rules that state that they will only pay the difference between what the primary carrier paid and what the secondary carrier would have paid if they were primary.

Consequently, enrolling in more than one dental plan makes sense if:
  • one plan provides benefits you need that are not provided by the other plan
  • one plan provides a greater reimbursement for dental services that you plan to use, and the percentage difference is greater than the cost of the premium of the second plan
  • enrollment is free
Unfortunately, this situation happens more often than it should... However, you are responsible for any charges incurred and not covered by the insurer if you "mistakenly" visit a non-participating dentist. Even if the dental office provided you with incorrect information... It is always the patients' responsibility to make sure that their dentist participates in their plan's network, if they want to take advantage of in-network benefits.

How to avoid this issue:

  1. Know which plan you are enrolled in and the plan's network. For example, if you are enrolled in the Delta Dental PPO Plus Premier plan, you would know by reading your plan summary that you have access to two dental networks (Delta Dental PPO and Delta Dental Premier). Both networks provide discounts and no balance billing.

    Also, a dentist may accept a different Delta Dental plan and just say "yes" if you ask if they accept Delta Dental. It is important to be specific when asking if a dentist participates in a certain plan and network

  2. Visit your plan's web site to find participating provider information online. You must still select the correct plan and, sometimes, network when using these tools.

    Remember that contracts between dentists and insurers may end at anytime; make sure the dentist is participating as of the date you receive services. Never assume that an online database of participating providers is up-to-date

  3. Call the insurer to confirm that the dentist is a participating provider and which network they participate in, so that you can get the maximum benefits from your plan

You should plan to do all of the above, not one or the other…

You can also request that the dentist accept the in-network reimbursement as payment in full, if they mistakenly informed you that they accepted your plan. Of course, they are under no obligation to do so, but if they want to keep you as a patient, they might.
Even if you did not change dental insurance plans during your annual open enrollment period, your plan's benefits may have changed. Insurers, with the approval of employers, make changes to dental benefits that are not always obvious to plan participants. Always review your dental plan information before visiting the dentist. Never assume, because you did nothing, that your dental plan benefits have not changed from year to year.
  1. Insurance companies may reduce dental care benefits through frequency limitations:
    • reducing fluoride treatments for minors from twice per year to once per year
    • replacing crowns every 10 years instead of every five years

  2. Dental insurance plan documentation may not be completely clear. For example, your benefit plan summary may state that crowns are covered, but leave for the small print that metal (silver) crowns, not porcelain (white) crowns are covered. Or the plans will pay for porcelain crowns for front teeth only. If your dental insurer only covers metal crowns, you may be responsible for paying the difference between the cost of the porcelain and metal crown. Some dental insurance policies provide benefits for the least expensive alternative treatment (LEAT), also called downgrading. With the LEAT provision, insurers may cover a percentage of a silver filling and the patient pays the difference between this amount and what the white filling cost. Some insurers may not pay anything for white fillings. Review your plan documents carefully

  3. Plan reimbursements are based on maximum allowable charges or usual and customary fees; it is almost impossible to accurately determine what the insurer will pay and what you will owe

  4. You may need more work than previously thought and the dentist may need to address these prior unknown issues while they have you in their chair
So, in addition to reviewing your plan documents, you should work with your dentist to submit a pretreatment estimate to the insurer. The insurer will determine what benefits will be covered and at what rate.

Reviewing your plan documents fully and working with your dentist and insurer, before you receive care, can reduce unexpected dental expenses.
  1. Deep cleanings (also known as scaling or root planing). Deep cleanings are needed when there is tartar beneath the gum line, separation of the gum tissue from the root of the tooth and inflammation of the gingival tissues. Deep cleanings are performed to prevent further loss of bone and gingival attachment that sometimes cannot be determined by x-rays alone. Therefore, a thorough periodontal evaluation by your dentist is required to determine the need for a deep cleaning.

    Dental insurers often use consultants to approve or deny claims for deep cleanings, and may not always have the best interests of the patient in mind.

  2. Transitional partial dentures. A dentist may provide a transitional partial denture (also known as a flipper) after removing teeth so that the patient does not have to walk around with a space in the mouth while awaiting a more permanent solution

This is when you learn just how far your dentist is willing to assist you in getting your “eligible” claims paid by the insurer. The dentist may have to appeal the denial several times before the insurer will pay the claim.
If you have dental insurance, you can prevent denial of dental care claims by following a few simple rules:
  1. Read plan documents, and not just the two-page summaries provided during the annual enrollment period. Ask for a copy of the plan's full summary plan description. These documents are often available in electronic format, making it easy to review only those sections related to your needs

  2. Review the benefits exclusions or (frequency) limitations section of your plan. This section will list which dental care services your plan will not cover, even if you want or need them, and it will state under what circumstances your plan may or may not cover other services

    For example, dental plans typically exclude coverage for cosmetic dentistry. Dental insurance companies categorize cosmetic dentistry as elective, not a necessity. The plans may also limit services for gum treatment, crowns, dentures, and implants within the first 12 months of the date your coverage starts

  3. Work with your dental care provider(s) to create a treatment plan and submit it to your insurer for a benefits review before the work is performed. Also, make sure your dentist obtained preauthorization, if required, and submitted all necessary and accurate paperwork to the insurer

  4. Make sure your dentist is willing to advocate on your behalf should a claim be denied (e.g., submit a letter of appeal or provide additional documentation).

THIS TOOL DOES NOT PROVIDE INSURANCE ADVICE. It is for general informational purposes and does not address individual circumstances.