3 of my 4 kids wear glasses and never has our health insurance covered the full cost of eye exam or glasses. We have Tricare Prime. Now my husband has GEHA dental which includes vision with EyeMed and that only gives a discount, doesn't pay for it. I just paid $105 for a eye exam and contact exam for my son. We did pay $40 for the Optomap.
The mandate went into effect in 2015 and it applies to your medical insurance, not riders like dental or separate vision plans.
From what I understand, Tricare Prime, Standard, Extra and TRS currently DO cover for yearly eye exams for children of active duty service members and every 2 years for non-ADFM children but only between the ages of 3-6 years. Just another example of our government exempting itself from its own mandates.
Coverage for materials (contact lenses and eyeglasses) is subject to the frame and lens type ordered and may not be covered completely under ANY insurance plan. However, the ACA mandates that children under 19 must be allowed to access the materials benefit every year (typically, adults are every 2 years but some excellent vision plans will also allow for annual materials benefits). Some plans provide an allowance per client toward frames & lenses or contacts and the consumer gets to spend that allowance as they see fit. Any overages are usually discounted. Some plans provide a discount for each. Some will cover nothing until you have met your OOP deductible, but may provide for a discount as contracted with the provider. And still others will provide the glasses at no charge if you choose from among the frames on their specialized selection of frames and single vision lens with upgrades paid by the client (although there are usually discounts on the retail price as a part of the provider's agreement with the insurance company).
Most vision plans (not the coverage under medical plans as mandated by the ACA) do not cover a contact lens exam, which is a separate exam that is not part of the routine eye exam but is done in addition to one. Nor do they cover for retinal imaging (Optomap is a company that makes imaging devices), unless the patient has underlying medical conditions that warrant following retinal changes (like diabetes). In those instances, the patient's medical plan (not their vision plan) should cover the test subject to the usual copays and deductibles and referrals from their PCP if the plan is an HMO.
The individual consumer is responsible for verifying their coverage and understanding their benefits and for ensuring that they use a provider that accepts their insurance. Otherwise, the consumer has to pay the provider 100% OOP, may not see that amount applied to their deductible and OOP maximum and would need to submit a claim for reimbursement for out-of-network services.
My glasses always need to be adjusted.
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