How is vision care covered under the Affordable Care Act?
The Affordable Care Act requires pediatric vision care coverage to be one of the essential health benefits. The ACA does not require insurers to provide coverage for routine vision care to adults.
What are the ACA rules for pediatric vision insurance?
For children under 19, visual coverage is included in all new small groups and individuals. health insurance (with effective dates on or after January 2014), on and off-exchange. This means children get coverage for eye exams, vision screenings, and glasses to correct vision problems.
The specific pediatric vision services that must be covered by individual and small group plans vary from state to state, depending on the reference plane the state uses. In most states, the Reference Plan’s pediatric vision coverage includes an annual eye exam and one pair of glasses, including frames, per year (“covered” does not mean no-cost coverage; there may be co-pays, deductibles and coinsurance for these services). You can see updated information on the reference plane for each state here.
Are eye exams for children covered by pediatric vision insurance?
Vision screening in children falls into the category of preventative carewhich means it is covered for free until children turn 19 (provided you have a ACA Compliant Plan).
But vision screening is not the same as an eye exam. A vision screening may be performed by a pediatrician or family doctor to identify or detect visual difficulties. The screening may not diagnose the child’s condition, but it can indicate whether the screening should be followed by a complete examination.
Although pediatric vision care beyond vision screening is covered by the ACA, anything other than vision screening may be subject to a copayment, or counted toward the deductible and/or covered by co-insurance. So, although the eye exam will be covered under the ACA’s pediatric vision coverage, the details of cost sharing will vary from plan to plan. Some carriers, however, offer free eye exams and glasses for children – it depends on the carrier, so read the fine print on the plans you’re considering.
Are contact lenses covered by pediatric vision insurance?
Generally, corrective contact lenses for children will be covered under individual and small group plans. But the details will vary from state to state, depending on the details of the state’s Essential Health Benefits Reference Plan. Some will distinguish between optional contact lenses and medically necessary contact lenses. Some only cover a partial year’s supply of contact lenses. Some only cover contact lenses instead of glasses, so a family won’t be able to get coverage for both in the same year.
It is also common for contact lenses to be subject to the health insurance deductible. This means the family would pay the full cost (after the discount negotiated by the health plan network) if the deductible had not yet been met for other services earlier in the year. After the deductible, the health plan would pay a portion of the cost of the contact lenses (assuming it is a covered benefit), subject to the plan’s coinsurance.
Is vision coverage for adults required by the ACA?
Routine vision care coverage is not required for adults by the ACA. Health insurance plans may choose to include adult vision coverage in their benefit design, but they are not required to do so.
If your employer offers health insurance, there’s a good chance that vision coverage will be included in your benefits package. If not, you can purchase a standalone vision plan. Depending on how much vision care you use, it may or may not make financial sense.
If the health plan you’re considering – on or off exchange – doesn’t include adult vision coverage, you may want to purchase a standalone adult vision plan. In most states, stand-alone vision plans are not offered through the exchanges, and even if they are, you cannot use your subsidy premium to offset their cost.
HealthCare.gov (used in 33 states from plan year 2023) do not offer any autonomous vision plan. But several fully state-run exchanges have established partnership agreements with an autonomous visual coverage company (VSP, in most cases: California, Colorado, CC, Idaho, KentuckyAnd Nevada). In these states, visitors to the exchange are directed to a link where they can purchase standalone vision coverage directly from the vision coverage provider.
Optometry versus ophthalmology
When we talk about vision coverage, we are generally referring to optometry care. This involves the process of vision testing and correction and is generally not covered by adult health insurance plans.
However, ophthalmology services for the treatment of eye injuries, diseases (such as cataracts or macular degeneration) or infections would generally be covered by health insurance policies, subject to the same cost sharing as other medical conditions. It is also common for health insurance plans to cover (subject to normal cost sharing) a pair of glasses after treatment for a cataract or an accident that damages one or both eyes.
Note that although LASIK surgery is performed by ophthalmologists, it is almost never covered by self-purchased health insurance; LASIK falls under the category of vision correction, rather than treatment of an injury or disease affecting the eye.
How much does vision insurance cost?
If you purchase ACA-compliant individual health insurance (in exchange or off-exchange), or by enrolling in an ACA-compliant small group health plan, pediatric vision coverage will be included in the plan, as described above. But keep in mind that the plan’s usual deductible and coinsurance may apply to all services other than vision screening (which is not the same as an eye exam).
If your employer offers separate vision coverage as part of your benefits package, they will likely pay part of the premium, making the monthly cost of coverage quite low.
If you want to purchase your own adult vision coverage, you’ll find plans with monthly premiums under $15 per person, although plans with enhanced benefits can cost more than $30/month. Stand-alone vision plans for adults typically cover an annual eye exam with a low co-pay ($15 is common) and will provide an annual allowance for frames and lenses or contact lenses ($150 allowance is common on basic plans, but more expensive plans will generally pay a higher amount).
How can people with Medicare get vision insurance?
Original Medicare (Medicare Parts A and B) does not include coverage for routine vision services. Coverage is provided for eye illnesses and injuries, so Medicare will pay for, for example, cataract surgery (subject to normal cost-sharing requirements; in most cases this means the Part B deductible and coinsurance).
Virtually all Medicare Advantage plans provide at least some coverage for eye exams and glasses, although details vary from plan to plan. There are many things to consider when choosing between Original Medicare and Medicare Advantage (here are several things to keep in mind). The visual benefit is only a very small part of the overall picture, but it is something to consider.
Louise Norris is an individual health insurance broker who has written about health insurance and health reform since 2006. She has written dozens of opinion and educational articles on the Affordable Care Act for healthinsurance.org. His updates on the state’s health exchanges are regularly cited by media outlets covering health reform and other health insurance experts.
