The statistics on eye diseases and vision loss in the US are frightening. Approximately 12 million people in the US aged 40+ have some form of vision impairment.
So, knowing whether your medical insurance protects your eyes is essential. And, more importantly, you need to know what your coverage entails.
Although many vision-related services may be covered by insurance, knowing what they are is essential.
In this guide to vision care and Obamacare, or the Affordable Care Act (ACA), we cover vision insurance, how it ties in with ACA-compliant health plans, and your various eye care options. So, to see the complete picture, keep reading and discover the best eye protection.
Does Obamacare Cover Vision?
Because eyesight is essential to the human experience, doing all you can to protect it makes sense. Ophthalmologists’ services can be expensive without insurance, though. So, your best bet is having health insurance to help with your vision care needs.
The ACA (commonly known as Obamacare) constitutes health reform laws that govern all health insurance plans since the ACA came into force in March 2010. One of the most significant reforms was the mandatory inclusion of what are known as Essential Health Benefits (EHBs).
One of these EHBs is vision coverage when required for children. Adults, however, don’t enjoy the same benefit. That is not to say that adults can’t get vision coverage under the ACA. Many ACA plans do offer good vision care. But it’s not mandated as an essential benefit like it is for children.
We’ll look closer at adults’ options for vision care and coverage in a moment. First, here are the facts about children’s vision coverage under the ACA.
Children’s Vision Coverage
All ACA-compliant health plans must cover EHBs, including eye care services and screening for children under 19. This is considered pediatric vision care and will not incur further costs.
Eye care services beyond vision screening, such as comprehensive eye exams, eyeglasses, or corrective contact lenses, may incur copayments, or coinsurance, or count towards a deductible. You’ll need to check the specifics of your insurance plan, as they can differ widely.
Take note that any vision care offered also only applies to insurance plans that fall under the regulation of the ACA. Not all insurance plans cover it. Short-term, travel, and fixed indemnity insurance do not necessarily have to meet ACA requirements, as they are not classified as major medical insurance.
Marketplace health plans may, but don’t have to, offer vision care to adults. However, some forms of insurance, while not major medical plans, cover vision care specifically. Adults who don’t have access to all the eye care they need on their basic health plan can use vision insurance plans.
What Is A Vision Insurance Plan?
What’s the difference between vision care coverage on your medical insurance and a vision care-specific insurance plan?
Vision care can be a part of your overall medical insurance, along with other coverage for other health care services. Vision insurance is a supplemental medical plan that reduces the costs of eye care for services not included in your health plan.
Like most types of supplementary insurance, it will be more affordable than a major medical plan. It should only cost about $15 to $30, on average, per month.
It is not sufficient as medical insurance and is intended to be used in addition to your primary health insurance. You can use vision insurance plans for both preventive eye care services and prescription eye care products.
How does this affect other eye care procedures, like elective eye surgery? One of the most common elective eye surgeries is LASIK. This is a laser-assisted procedure that can improve nearsightedness, farsightedness, and astigmatism.
The cost of LASIK eye surgery without insurance can be high. Some medical insurance plans will cover it in full. Still, more often than not, they won’t because LASIK is an elective eye surgery.
Elective eye surgery is planned and scheduled eye surgery rather than being performed as an emergency or urgent procedure. These surgeries are typically not medically necessary to save a person’s life or preserve their vision immediately. Instead, doctors perform the surgery to improve a patient’s vision, correct refractive errors, or address eye conditions that may significantly affect their quality of life.
Getting Adult Vision Coverage
The ACA does not mandate routine vision care coverage for adults. Health plans can opt to include adult vision coverage, and several of them do, but the law does not require them to do so.
Of course, you could opt for a supplementary vision insurance plan (see above). While the federal ACA website does not offer such plans, many state-run exchanges have established partnership arrangements with insurers offering standalone vision coverage.
California, Colorado, DC, Idaho, Kentucky, and Nevada are states that link to such insurance options on their state-run exchanges.
Embedded In Your ACA Plan
It’s much simpler if your vision coverage is embedded in your ACA coverage. Many ACA plans offer some vision care coverage. They may even cover the costs of medically necessary cataract surgery. That’s a good thing because the cost of cataract surgery without insurance can be very high.
ACA plans will cover most medically necessary eye treatments. However, the distinction is made between routine preventive eye care and urgent or emergency eye care. The ACA does not require vision coverage or preventative eye care for adults.
Not all ACA plans are as stringent, but you should always check the details of your specific plan. A licensed broker like Enhance Health can help you make sense of all the small print that sets out the terms of the plan’s vision care coverage.
Medicaid And Vision Care
Medicaid is a federally funded health insurance program for US citizens requiring financial assistance. It is not an ACA insurance plan but the forerunner of this health reform law. One of the ACA’s primary original directives was expanding Medicaid coverage.
As part of its Early Pediatric Screening, Diagnostic, and Treatment (EPSDT) program, Medicaid covers eye care for children and young people under 21. This includes comprehensive eye exams and prescription eyeglasses.
For those over 21, only medically necessary eye care, like treatment of eye injuries, eye diseases, and infections, is covered. Routine eye exams, prescription eyeglasses, or corrective contact lenses may be covered, but it’s not mandatory. You’ll have to check with your state’s Medicaid offices.
Medicare And Vision Care
According to the American Academy of Ophthalmology, approximately half of all Americans have cataracts by age 75. And by age 80, 10% of Americans have late age-related macular degeneration (AMD), which can lead to vision impairment.
But you don’t have to accept this fate because while cataracts are not preventable, you can remove them with cataract surgery. Similarly, AMD is not preventable. Sadly, it’s not curable, but the right medical interventions can slow down the progression of this eye disease.
So, if you’re a senior, you may be interested in the vision care benefits of Medicare. Medicare is a federally funded health insurance program for US citizens over 65. And here at Enhance Health, we can help with Medicare enrollment, too.
Original Medicare (Parts A and B) does not include routine vision care coverage but does cover treatments for eye diseases and injuries. Medicare will pay for necessary cataract surgery (subject to the cost-sharing requirements such as the Part B deductible and coinsurance).
Most Medicare Advantage plans provide some coverage for eye exams and eyeglasses. As always, the specifics can differ from one plan to the next.
Eligibility Requirements For Vision Cover
Eligibility requirements for vision coverage for adults can vary depending on the specific insurance plan or program you’re considering. Here are some standard eligibility criteria and considerations:
- Age: Most vision insurance plans are available to adults aged 18 and older. However, some plans may offer coverage for children as well.
- Employment: Many people get vision coverage through their employer as part of their employee benefits package. In this case, eligibility is often tied to being an active employee.
- Medicaid: Medicaid eligibility varies by state, and vision coverage may also vary. Eligibility is often based on income and other factors, so you must check with your state’s Medicaid program.
- Individual Vision Insurance: Eligibility for these plans typically depends on your age, location, and willingness to pay the premiums.
- Specific Eye Conditions: Some vision insurance plans may have eligibility criteria related to specific eye conditions or needs. For example, you may be eligible for particular coverage or benefits if you have a diagnosed eye condition.
It’s important to note that vision insurance plans can vary significantly regarding coverage, cost, and eligibility criteria.
At Enhance Health, we know that vision is a precious gift one should never take for granted. Vision care can be expensive without insurance, so your next step is to get yourself covered. By choosing and signing up for insurance with good vision care, you’ll safeguard your eyesight for years to come.
We make choosing the right health insurance plan easy, helping you find one that fits your eye care needs and budget. So, contact us today for expert advice and assistance, and rest assured you have protected your eyes and your pocket. Our qualified agents are standing by for your call.