Gailey Eye Clinic is a participating Medicare provider. We are also participating providers with most major medical plans and vision plans. To help our patients understand how we bill for eye exams, we have outlined the difference between medical eye exams versus routine eye exams below. It is the patient’s responsibility to verify benefits with their insurance carrier prior to their appointment.
Office visits to an eye care professional are typically classified as either “routine” or “medical”. The type of eye exam you have is determined by the reason for your appointment or your chief complaint, as well as the diagnosis given by your doctor. It’s important for patients to understand the difference between a routine exam versus a medical exam because insurance carriers will cover the exam only if that type of exam is included in your plan. Medical plans typically do not cover routine eye exams and vision plans do not cover medical eye exams.
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.
Vision insurance plans provide coverage for routine exams, glasses and contact lenses, or at least provide some type of discounts on your doctor’s fees. A routine eye exam is billed to your vision insurance plan (VSP, EyeMed, Humana VCP). By law, Medicare does not pay for routine vision exams.
A medical eye exam is typically scheduled when the patient is experiencing a problem with their eyes that goes beyond needing new glasses or contacts. A medical eye exam produces a diagnosis, like conjunctivitis (pink eye), stye, dry eye, glaucoma or cataracts, to mention a few. Examinations for medical eye care, assessment of an eye complaint or to follow up on an existing medical condition are billed to your medical insurance plan.
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. Typically vision insurance plans cover both the eye exam and the refraction, but some do not. If vision insurance does not cover the cost of the refraction, it is the patient’s responsibility to pay for the refraction fee. Medical insurance will not cover the cost of a refraction.
We understand that determining if an eye exam is classified as “routine” or medical” can be very confusing. It’s important to remember that “routine” vs. “medical” has nothing to do with the steps involved in an eye exam or the type of doctor (Ophthalmologist vs. Optometrist) who performs the eye exam. A routine eye exam has similar components to that of a medical eye exam, but insurance carriers focus on the reason for the exam, or the chief complaint to determine if the exam is routine or medical in nature. If you have questions regarding insurance and/or billing, please call our Patient Accounts Department at 309-829-5311.
* Having insurance coverage doesn’t necessarily mean your insurance carrier will cover the total cost of your eye exam. Many health plans have copayments and deductible 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 the proper insurance to cover your exam, whether it’s medical or routine. Your insurance carrier will also be able to determine if our doctors are in-network providers in your plan.
We offer a variety of payment options and financing, including:
* Financing through Care Credit* (apply now)
* Flexible Spending Accounts
* Credit Cards (We gladly accept Visa, Mastercard, Discover)
* Care Credit can only be used for surgical procedures.