eye exams and insurance

[clori]

DD9 needed glasses for distance the first time last March and the eye dr (pediatric opthamologist) told us she predicts her vision will gradually get worse. A few weeks ago dd said she didn't think she was seeing that well with her glasses. I called and got her an appt relatively quickly due to a cancellation.

It turned out I made dd's appointment 1 day shy of of 365 days. The claim was rejected. The eye dr's billing department told if I could try calling the insurance company and nicely see if they would do a one time courtesy adjustment. When I called the insurance company I was informed that unless there is a medical reason only one eye exam is covered every 24 months. A change in vision is not a medical reason to see an opthamologist since it is still just a routine exam therefore it isn't covered. The eye dr's office offered to try to rebill it mentioning a few things like allergies but most likely it isn't covered. Fortunately it will be $85 for a returning patient vs the $250 bill I thought.

Due to unemployment and the fed insurance subsidy ending for us the end of May I've done some insurance research and it seems that they now just cover routine eye visits once every 24 months. I really wish for kids it would be covered every 12 months. There isn't any medical reason but to me a child not seeing properly after close to a year should be reason enough for an eye exam. With money being tight it is a nuisance but even if I realized it was a year early I still would have taken dd to the opthamologist after she mentioned not seeing correctly with her glasses on.

 

[msmayor]

Not every plan is 24-months. It more than likely is tied to what your employer is willing to include in their coverage.

The vision plan we have through DH's employer allows one regular exam each calendar year, so we are not even tied to the restriction of making sure the next exam is at least 365 days after the previous. Our regular health insurance also covers one visit, though we never use that piece of coverage since we have the vision plan.

 

[Mommee]

Is there a reason your daughter is seeing a pediatric ophthalmologist instead of a regular ophthalmologist or an optometrist? I do believe it's much cheaper, and if she doesn't have medical issues she'd be fine.

I'm also a bit jealous. DD (3) has eye issues and we have to drive over an hour to even find a pediatric ophthalmologist, and the place is always SO crowded..it's a day-long excursion!

 

[bridget]

Wow- this post is going to make me go back and re-read my health insurance policy. I know I have to go the eye dr. every 3 month. I went in Feb, and I go back in May. Before I go, I'm checking my policy!

 

[dd50]

I took my daughter to the eye doctor when I didn't even know that we had coverage. The following year I took her with coverage and it ended up costing me the same amount of money because with my plan (under insurance) they didn't pay for child safety glasses, didn't cover the UV tint, and some thing else.

 

[Kitzka]

do you have separate vision care from your medical care? i think all plans are deifferent. DD can see the eye dr every year. for our family it's pretty important as i had bad eye sight and glaucoma as a kid (well, i still have glaucoma).

I saw a pediatric ophthamologist when i was a child and always had VERY long waits. I now see a reg optomitrist and there is a much shorter wait and it's much cheaper. it goes through my vision plan rather than my medical plan.

maybe look into seeing an optomitrist?

lara

 

[pooh4brains]

Usually folks see an MD (ophthalmologist) for a medical reason - glaucoma for example, and the exam is billed through the medical insurance. I worked for ODs (optometrists) and they billed through specific eye insurance. Before a patient came in we knew if they were eligible for the services b/c they had to be authorized before they sat in a chair for the exam - otherwise they paid out of pocket. I would think that it works the same in the case of your ophthal. Shouldn't the office know if you are eligible? Don't they have to get authorizations before you come in to ensure that you are covered and that they are going to get paid for the services you receive?

It's not going to help now, but maybe ask the office manager or the person in charge of billing how it works and who is supposed to check so you don't wind up paying again. I know in this case you needed it b/c her vision changed...

 

[Nancy F]

The Insurance companies are a real PITA. How much did they charge you for a routine exam?? Our Dr. charges $45.00 without insurance. And that's a full exam. What could your Dr. possible do for $250.00 ??? $85.00 is insane too for a 9 yo.

Nancy

 

[pezheadmeg]

Are you going through medical or the vision insurance?

My medical insurance never gives me issues with seeing my opthamologist. If they only covered one exam every 24 months I would be having major issues. I've had eyes with issues since kindergarten, waiting for coverage could be disatsrous.

 

[bear_mom]

I think it depends on your insurance. I had to take dd to the eye doctor 7 months after her last appt. for new glasses . It was a different calendar year, which is important for our insurance. Plus dh wants to take her back before school starts in the fall, I don't think that one will be covered though.

Emily

 

[SandrA9810]

That sounds strange. Even the basic (free for employees, and a couple dollars more for family) allows for eye exams every year. Now the basic allows for only new lenses once per year, and the high vision allows for frames and lenses once per year. But they go by calendar year... not rolling 12 months.

 

[mamalle]

we have separate vision insurance and use a optometrist for our annual exams. if we use our medical and see a ophthalmologist it would have to be medically necessary like a corneal abrasion, etc.. hubby has used that in the past before.

 

[kelleyrn2000]

We have vision insurance through DH's employer (UAW). They only pay for vision exams and glasses once every 2 years. My dd (8) needs new glasses every year unfortunately. This past year we paid $60 for her exam (non covered year) then $120 on new glasses for her. So basically it will cost us $200 for her every other year. This was cheaper than me getting vision coverage through my employer so we opted to do that.

I ended up having the Lasik surgery a few years ago. I wore contacts and glasses, plus my Rx changed every year. DH's insurance didn't cover contacts at all, so I was spending a fortune. So glad I was able to get the surgery. Unfortunately we will just have to spend the money for dd, and hopefully her younger siblings won't need glasses too!!!

 

[dldwmom]

My 12 year old has had glasses for 7 years now, and the only way that it is covered is through a medical reason for his pediatric opthomologist. This year his astigmatism changed, and we wound up taking him to Costco and just paid for it, as well as new lenses on our own. We have found the warehouses quite good for prices, especially for extras when you have a child with a high correction and astigmatism. Good luck!

 

[taximomfor4]

Of my 4 kids, all 4 wear glasses ... The optometrist that dd16 and I see saw my others, and for different reasons, had to refer them to a pediatric opthalmologist. So dd16 and I, with just regular vision issues, use our separate vision insurance, good for an eye exam every calendar year and a certain amount toward glasses every 2 yrs. DD16 complained several months after getting her glasses that things were looking a bit fuzzy. I asked how bad it was, to gauge if we could wait another month to get into the next calendar year, or if she needed to get into the optometrist sooner. She was perfectly fine waiting. If it had been too long to wait, I would have taken her and paid Out of pocket, of course.

The 3 who see the ped. opthalm. go more often, and for more complicated things. It's covered under our medical insurance with our normal medical-insurace copay, but still only get glasses every 2 yrs.

For glasses, I take them to Walmart. I've gotten frames for $8 for them there. Since one dd just went into bifocals (over $200 at Walmart!!), I will continue buying them cheap frames. 3 of my kids have been in glasses full time since 2 yrs of age, and we've never had a pair of lost or broken glasses yet. *KNOCK ON WOOD!*

 

[kelleyrn2000]

Of my 4 kids, all 4 wear glasses ... The optometrist that dd16 and I see saw my others, and for different reasons, had to refer them to a pediatric opthalmologist. So dd16 and I, with just regular vision issues, use our separate vision insurance, good for an eye exam every calendar year and a certain amount toward glasses every 2 yrs. DD16 complained several months after getting her glasses that things were looking a bit fuzzy. I asked how bad it was, to gauge if we could wait another month to get into the next calendar year, or if she needed to get into the optometrist sooner. She was perfectly fine waiting. If it had been too long to wait, I would have taken her and paid Out of pocket, of course.

The 3 who see the ped. opthalm. go more often, and for more complicated things. It's covered under our medical insurance with our normal medical-insurace copay, but still only get glasses every 2 yrs.

For glasses, I take them to Walmart. I've gotten frames for $8 for them there. Since one dd just went into bifocals (over $200 at Walmart!!), I will continue buying them cheap frames. 3 of my kids have been in glasses full time since 2 yrs of age, and we've never had a pair of lost or broken glasses yet. *KNOCK ON WOOD!*

LOL you should see my dd! She has destroyed her glasses so many times! When we pay out of pocket, we only shop places that have exceptional warranties (Sam's and Shopko). Her last pair had to be replaced twice ( ones covered by insurance, ordered from the eye doctor...luckily those were warrantied too) so when we found out Shopko had an unlimited warranty too, we chose to get our out of pocket ones from there, just in case.

DD is very accident prone. Destroyed one pair by freak bike accident (the child hit a curb going downhill too fast and went flying off the corner of a bridge into a ravine of rocks!) and at school (took them off to color with chalk??? and some kid trampled them beyond repair) and has let her baby brother grab them and pull on them quite a few times. Hopefully when she is a bit older, she will take better care of them.

 

[disfan07]

I go tothe opthamologist every 6 months or as needed if i notice problems. I went in june of 2009 and than i went in january of 2010 and it was covered both times.

we have separate vision insurance through my dads job but the opthamologist is my dads coworkers wife so if we werent covered we would get a discount anyways.

But my situation is different. teh appointment in june was a regular visit and the appointment in january was ordered by my neurologist to see if vision problems i was having were my eyes or if it was symtoms of the benign tumor that they had found so that may be why mine is covered so often. because i have been wearing glasses since 3rd grade but i was only getting my eyes checked about every 3-5 years before this started

 

[clori]

Thanks for all the replies. The charge that was billed to the insurance company was $250 but if I pay directly it is $85. I have no idea why it is higher here. I live a few miles away from Boston if location matters. It is easy enough to get appts with a pediatric opthamologist here and there are places like Childrens Hospital opthamology and Mass Eye and Ear if needed though we go group outside of Boston. Dh has really bad vision that I don't fully understand but his strength is something like -15.xx in both eyes, astigmatism,lazy eye, barely attached retina in one eye etc and his type of vision tends to run in families. I just have basic nearsightedness.

When we first moved to our new city about 10 years ago we did go to an optometrist who was really good but has since passed away. We switched to a different optometrist who got the old one's info - again nice person who retired and we found out recently also passed away. Basically when dd5 had her 3 year check up the ped thought dd had lazy eye and told me to call a certain eye drs office. I just called the number she gave me and it turned out to be a group practice with mostly opthamologists. We took dd in and she doesn't have lazy eye. I guess dh's eyeglasses give away enough info so the opthamologist talked to him and recommended we all come in even though at the time older dd had perfect vision. Dh really should be followed by an opthamologist anyway. The dr dd5 saw is a pediatric opthamologist but she also sees adults so gradually we all saw her and the appts have always been covered by our medical insurance.


The medical insurance covers routine eye exams with either an optometrist or opthamologist as long as it is within the allotted time period but medical reasons more frequently. I was the one who made the mistake in not thinking that needing a new prescription wasn't medical but also I just didn't realize it was switched to 12 months to 24 months. I just looked at the blue cross website and it says it coveres routine eye exams once every 24 months by either a physician (opthamologist) or an optometrist. Referrals aren't needed. Also since dh was seen in January this year and it was covered I didn't think anything. I'm guessing his was put thru as medical because he had to have a second appt with a retina specialist. I guess somehow the change to cobra about the same time the plan changed I missed seeing the change in coverage from every 12 months to every 24. Now that I know younger dd and I will wait another year unless issues come up.

We do not have a vision plan because dh doens't like the glasses he has gotten using the plan and since this eye drs office doesn't accept the plan etc it didn't seem worth it to keep on cobra paying the full price especially before we knew about the federal subsidy. I paid $44 for a pair of glasses for dd at foreyes which include polycarbonate lenses, uv protection, scrath resistant coating and a 1 year replacement warranty. They don't have anti glare and I didn't ask about the increased price for that.