Find vision insurance or eye care insurance for individuals and families.
When you’re looking for vision insurance, UnitedHealthcare branded vision plans, underwritten by Golden Rule Insurance Company, may help you get more of the benefits you want. Choose from a range of options designed to help you cover and budget for ongoing vision care expenses. Read on to find a vision plan that’s right for you.
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What does vision insurance cover?
With vision insurance, you’ll typically have benefits that cover some of the routine costs for vision care, like routine eye exams, glasses or contact lenses. 1 You can buy vision plans to add to your health insurance or choose to buy vision coverage along with other supplemental plans, like a dental plan. 2
See why choosing a vision insurance plan may be worth it for you
Vision insurance plans can help you better manage your vision care costs by giving you the benefits you need to stay on top of your eye health. With a vision plan you can:
Lower your out-of-pocket costs for eye care
When you choose a network provider (Out-of-network providers are also covered, but without discounts)
Get coverage for the eye care you need
Coverage for routine eye exams on day one of your plan
Pick the prescription eyewear you prefer
Coverage available for standard eyeglass lenses and frames and contact lenses 1
Frequently asked questions about vision insurance
Want to learn more about vision insurance and how it works? Explore these vision insurance FAQs to help you choose a plan that best meets your needs.
How does vision insurance work?
Vision insurance plans offer coverage for eye care that’s often not covered by a health insurance plan. So, when you choose a vision plan, you’ll pay a premium to have coverage for routine eye exams to check your vision health, as well as prescription eyewear benefits. 1
How do I get vision insurance?
There are 2 ways to buy vision insurance plans, underwritten by Golden Rule Insurance Company.
- You can choose a standalone vision plan. 1 This means you buy a vision plan separately, to add to your health insurance.
- You can choose to combine your vision coverage with a dental plan. Plan design varies by state, but in most places, you can find either a dental plan that includes vision coverage or one you can add vision coverage to. 2 Put simply, if you're considering dental coverage already, you may want to see if combining vision insurance makes sense.
How can I find a vision provider near me?
Search for providers in our large national UnitedHealthcare network at myuhcvision.com .
Does vision insurance cover contacts, glasses or both?
With vision insurance, most plans will cover prescription eyewear. When you're shopping for a vision plan, you'll find most states have plans including coverage for both glasses and contacts. 1
If my Medicare plan doesn't include vision benefits, can I apply for vision insurance?
Yes, UnitedHealthcare branded vision plans are available for people of all ages. 3 So if you’re looking for a vision plan to add to your major medical coverage, like Medicare, explore our vision plan options .
Why choose vision plans from UnitedHealthcare?
Find vision coverage for you and your family — it's available for all ages. 3
Save by choosing a provider from a large national network of vision service and eyewear providers.
No waiting periods
Get access to vision care on day 1 of your plan — no waiting period.
Experience the freedom to go out of network and still get benefits if you pay the difference between your plan allowance and your final cost.
Explore more supplemental plans
View more plans, like dental and cash- benefit plans, that offer coverage for expenses not covered by a medical plan.
Need help finding a plan?
Answer a few questions to see which insurance options may be available for you.
Already a member with a vision plan?
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Spectera Vision Insurance Coverage
In this article
VSP offers flexible vision insurance coverage, built just for you. Learn More
What is Spectera Vision Insurance?
Vision insurance is a type of health benefit. It fully or partially covers the following:
- Eye disorder treatments
- Contact lenses. 7
Spectera is a type of vision insurance, underwritten by Golden Rule Insurance Company. It offers significant cost savings on eye care and eyewear.
Spectera vision insurance is tied to a broad provider network, allowing you to choose eye doctors and eyewear freely. This includes both ophthalmologists and optometrists. 3
What Does Spectera Cover?
Spectera has many vision benefits that cover a variety of eye-care needs. While plans vary and different eye doctors offer unique services, Spectera generally covers:
- Lenses (including single-vision lenses, bifocals, trifocals , and lenticular lenses , as well as a standard scratch-resistant coating for lenses if prescribed)
- Contact lenses (including bifocal contact lenses, gas-permeable contact lenses, soft contact lenses, and disposable contact lenses)
- Prescription sunglasses
- Eyeglass frames
- Eyeglass fittings and adjustments
You may be covered for one eye exam in a 12-month period. Likewise, many plans offer new coverage for lenses or frames every year.
If you choose disposable contact lenses over extended-wear lenses, you may be eligible for coverage of several boxes yearly. Check the different vision plans to ensure you choose a comprehensive vision care plan that covers your needs.
Need vision Insurance? VSP has plans as low as $13/month. View Plans
What Doesn’t Spectera Cover?
While plenty of Spectera benefits help you cover the costs of your eye care, remember that not everything is covered. Unfortunately, Spectera doesn't cover:
- Certain surgical eye procedures
- Corrective vision treatments
- Experimental vision treatments
- Missed appointment charges
- Sales tax charges on services for vision care
- Eye exams required by employers as conditions of employment
- Eye care extras, like accessories
- Certain cosmetic contact lenses, like colored contacts
- Nonprescription eyewear (only prescription glasses and contacts are covered)
- Nonprescription contact lenses
- Broken eyeglasses
Also, if your eye doctor is not one of Spectera’s in-network providers, you may have to pay out of pocket. Similarly, if you need to purchase more contact lenses than your plan allows, you may need to pay out of pocket for them. Additional services, like more eye exams, may not be covered either.
What is the Benefit of a Spectera Vision Plan?
Various types of Spectera vision plans cover all or part of eye care costs with no waiting periods. 3 With these plans, you gain access to 20 to 40% discounts on:
- Various lens options
- Extra eyewear
- Laser vision correction
- Other vision services 3
VSP insurance coverage can help you save on glasses, contacts, eye exams, and more. Learn More
Types of Spectera Plans for Vision Coverage
There are several different types of Spectera plans for vision coverage. No two plans offer the same benefits.
You also have the option to choose from standalone vision insurance plans that cover glasses, contacts, or both. Or, you can combine dental insurance with your vision insurance through Spectera. 6
Plans vary by state. Generally, you have two options:
- Plan A : This covers your needs for eyewear or contact lenses instead of glasses
- Plan B : This covers your needs for both contacts and glasses
Some states have a 12-month initial policy requirement.
Who is Eligible for Spectera Vision Insurance?
Spectera vision care insurance offers coverage for people of all ages. However, the primary insured must be at least 18 years old . 3
Even people who are already covered under Medicare can apply for Spectera vision insurance.
Does Spectera Cover LASIK?
LASIK (laser-assisted in situ keratomileusis) is a type of refractive eye surgery that offers permanent results. 1 It uses lasers to correct issues like:
- Myopia (also known as nearsightedness)
- Hyperopia (also known as farsightedness)
However, insurance never covers LASIK eye surgery since it's considered an elective procedure. Most health insurance companies consider laser eye surgery a cosmetic procedure.
They do not cover laser eye surgery costs because it's not medically necessary. 1 Nonetheless, there are some alternative ways to help you save on LASIK eye surgery:
1. Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs)
Some patients tap into their FSAs or HSAs to cover the costs of LASIK. FSA and HSA accounts are both pre-tax accounts that you can use to pay for LASIK. 2
FSA accounts are offered through your employer and are typically tied to traditional health plans. Meanwhile, HSA accounts must be linked to plans with high deductibles. 2
2. Health Reimbursement Accounts
Health reimbursement accounts are employer-funded health benefit plans that reimburse employees for certain out-of-pocket healthcare expenses. In some cases, they may also cover the costs of premiums for health insurance plans. You may be able to use a health reimbursement account to cover LASIK. 2
3. Special Deals
Some eye care doctors or offices offer special deals. They may offer promotional discounts to attract and retain new patients.
4. QualSight LASIK
Q ualSight LASIK makes up the largest network of credentialed LASIK eye surgeons across the U.S. With Spectera insurance, you can access discounted laser procedures through QualSight LASIK. 5
Talk to your eye doctor about whether or not LASIK is right for you. Your Spectera vision provider can also discuss alternative options.
Spectera Vision Insurance offers coverage and significant savings for eye care and eyewear. They offer various plans that provide 20 to 40% discounts on vision services.
Coverage is available for people of all ages. Remember to ask your doctor whether they're one of Spectera’s in-network providers.
Keep in mind there are things that Spectera doesn't cover. You should confirm whether your insurance covers the costs of your eye care needs.
VSP has the nation's largest network of independent vision doctors. Protect your health and save money today. Check Their Network
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- Boyd, Kierstan. “ LASIK - Laser Eye Surgery .” American Academy of Ophthalmology , 2021.
- “ Financing LASIK or PRK .” LasikPlus .
- “ Health Insurance .” Add Vision Insurance To Your Health Coverage | UnitedHealthOne .
- “ Vision Plan Frequently Asked Questions .” Saint Mary's .
- “ Schedule Your Free LASIK Exam Today! ” LASIK Eye Surgery: Largest LASIK Plan in the USA | QualSight LASIK .
- “ Spectera .” Spectera .
- “ Vision Coverage - Healthcare.gov Glossary .” HealthCare.gov .
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A Guide to Billing for Medically Necessary Contact Lenses
Yasmeen Lakhani, OD
Christopher Wolfe, OD, FAAO, Dipl. ABO
Navigating vision insurance plans and billing codes can be a headache, but armed with the right knowledge, you can make a massive impact on patient lives.
Editor's note: This article was originally published in March of 2019, but has been updated for 2022.
- Medically necessary contact lenses can be soft (such as disposable or extended wear), hybrid (such as rigid gas permeable with a soft lens skirt) or hard (rigid gas permeable or scleral) contact lenses
- Be sure to understand the specific requirements for each managed vision plan
- When billing for medically necessary contact lenses, CPT codes 92071, 92072 and 92313 are not meant to be used simultaneously: it’s one or the other
What are medically necessary contact lenses?
Vision insurance plans, covered conditions.
- Anisometropia exceeding 3D in meridian powers
- High ametropia exceeding -10D or +10D spherical equivalent in one or both eyes
- Vision Improvement for patients whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses
- AND spectacle best-corrected visual acuity of 20/40 of worse in either eye
- AND visual acuity improvement of 2 lines or more with contact lenses
- Irregular Astigmatism of 2 diopters of astigmatism in either eye, with principal meridian separated by less than 90 degrees.
- Anisometropia of 4.0D or more, provided visual acuity improves to 20/60 or better in the weaker eye.
- Aphakia (after cataract surgery) A pair of single vision lenses or multifocal lenses and frames can be provided with the contact lenses.
- Vision Improvement when visual acuity cannot be corrected to 20/70 in the better eye except through the use of contact lenses (must be 20/60 or better)
- Anisometropia exceeding 3D meridian power based on the spectacle prescription
- High ametropia exceeding ±10.00 in one or both eyes based on the spectacle prescription
- Hereditary Corneal Dystrophies
- Congenital anisocoria
- Pupil abnormalities
- High ametropia
- Accommodative disorder
- Binocular function disorder
- Different prism requirements for distance and near
Working with a variety of vision insurance plans will require proper credentialing for each. Check out our Ultimate Guide to Optometry Credentialing!
Current Procedural Terminology (CPT)
Healthcare common procedure coding system (hcpcs).
Eyes On Eyecare has partnered with EyeCode Education to bring our members the best in coding and billing education!
Looking for a more general guide to billing? Check out the Ultimate Guide to Optometry Billing and Coding!
Yasmeen Lakhani received her Doctorate of Optometry from Southern California College of Optometry at Marshall B. Ketchum University. She is passionate about family eye care and building strong relationships with her patients and colleagues to promote optometry. She is currently practicing at a private practice in Los Angeles, California.
Dr. Christopher Wolfe is a graduate of Northeastern State University Oklahoma College of Optometry. While in school, he served as president of the American Optometric Student Association, where he represented over 6,000 members. He is currently the Chair of the American Optometric Association’s State Government Relations Committee and the Legislative Chair for the Nebraska Optometric Association. In 2013 and 2015 he was awarded Young Optometrist of the Year for the Nebraska Optometric Association. In 2016 he was awarded the Optometrist of the Year for the Nebraska Optometric Association and the Young Optometrist of the Year for the American Optometric Association. In 2014 he was awarded Political Keyperson of the Year for the Nebraska Optometric Association and Alumni of the Year from Skutt Catholic High School.
Dr. Wolfe has a passion for education. He is a co-founder of KMK Board Certification Review Services, a company specializing in preparing Doctors of Optometry to take the American Board of Optometry examination. He is the founder of EyeCode Education, a company specializing in clinical and billing education. Dr. Wolfe is a fellow in the American Academy of Optometry and a Diplomate of the American Board of Optometry. He also has special interests in therapeutic scleral contact lenses to correct visual distortions in patients with corneal diseases. Dr. Wolfe is an avid runner and most of all, he enjoys spending time with his wife Jaime, daughters Ryan, Paityn, Camryn, Logan, Maisyn and sons Lincoln, Deacon, and Benton.
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Ensuring Compensation When Fitting Medically Necessary Contact Lenses
Insights into billing and coding for these services.
Roxanne Achong-Coan, OD, FAAO, FIAOMC, FSLS
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Fitting specialty contact lenses isn’t always as straightforward as fitting conventional contact lenses, but broadening your skill set can open up a wider, more diverse patient base. As the health care system evolves, more eye care practitioners are moving toward the medical model of optometry, and one of the fastest growing areas in the profession is medically necessary contact lenses. Billing and coding for this service with different insurance providers are constantly changing, which can be confusing. In this article, I provide some guidance on what constitutes medical necessity, common codes, and things to keep in mind when dealing with vision insurance.
Following are Current Procedural Terminology (CPT) codes from the American Medical Association that describe the fit if performed by a physician or technician for medically necessary contact lenses. 1
The prescription of contact lenses includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, oxygen permeability). It is not a part of the general ophthalmological services.
The fitting of a contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.
Follow-up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service. (92012 et seq) The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code.
The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code.
92310 (92314*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens, Both Eyes, Except for Aphakia
92311 (92315*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens for Aphakia, One Eye
92312 (92316*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens for Aphakia, Both Eyes
92313 (92317*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneoscleral Lens
(*) Denotes codes for same service when provided by a technician.
92071 – Fitting of Contact Lens for Treatment of Ocular Surface Disease. This usually refers to bandage contact lenses used to manage recurrent erosions and corneal abrasions.
92072 – Fitting of Contact Lens for the Management of Keratoconus. Verify with the insurance company what criteria are required for the diagnosis of keratoconus and grading of its severity. Also, determine if the insurance provider prefers that lenses be billed for separately or as a bundle.
9921X or 92012 – For Subsequent Fittings Report Using Evaluation and Management Services or General Ophthalmological Services
After the fees, timeline, and expectations of the contact lens evaluation process have been discussed, it is important to have patients sign a written contract that includes an advance beneficiary notice (ABN). ABNs require patients to make an informed decision on whether they or their insurance company will pay for the services and goods provided. If the claim is denied, patients are aware that they are financially responsible. The written contract discusses all the charges involved in the treatment plan (eg, office visits, warranties, lens upgrades, supplies needed, timeframe of the treatment plan).
An ABN offers the following three options 2 :
Option No. 1
I want the ______ listed above. You may ask to be paid now, but I also want _____ billed for an official decision on payment, which is sent to me on a summary notice. I understand that, if _______ doesn’t pay, I am responsible for payment, but I can appeal to ______ by following the directions on the Medicare summary notice. If _______ does pay, you will refund any payments I made to you, less copays or deductibles.
Option No. 2
I want the ______ listed above, but do not bill ______. You may ask to be paid now because I am responsible for payment. I cannot appeal if _____is not billed.
Option No. 3
I don’t want the ______ listed above. I understand that, with this choice, I am not responsible for payment, and I cannot appeal to see if _____would pay.
These codes (Table 1) are used to bill for the materials (ie, contact lenses) and may have a modifier for the right or left eye. These codes are used on insurance forms and are universal. You may also have to indicate the quantity of lenses.
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Every vision insurance provider has its own expectations. Following are some key points to keep in mind when fitting medically necessary contact lenses for patients with EyeMed Vision Care, VSP, and Spectera, which are the three insurance providers my practice deals with most often.
EyeMed Vision Care
EyeMed considers contact lenses medically necessary if a patient is diagnosed with anisometropia, high ametropia, mild or advanced keratoconus, or vision improvement (Table 2). 4 The provider will then submit clinical documentation, corneal topographies (for patients with irregular corneas), and Health Care Financing Administration form to the patient’s insurance, which will usually approve or deny the claim within 1 to 2 weeks.
In order to verify what VSP considers medically necessary, log in and scroll down to visually necessary contact lenses (NCLs) under “plans and coverage” in the “manuals” section. 5 Specific eye conditions can be corrected only with contact lenses. These include:
- Anisometropia in which the difference based on the spectacle prescription is 3.00 D or more;
- High ametropia (≥ ±10.00 D) in either eye based on the spectacle prescription;
- Achromatopsia, polycoria, congenital anisocoria, and certain pupillary abnormalities;
- Corneal transplant;
- Hereditary corneal dystrophies;
This claim can be filed electronically on e-Claim. No prior authorization is required.
For patients with high ametropia or anisometropia, it is important to enter the spectacle prescription into the lab order so the insurance provider can verify that the condition meets medically necessary requirements.
When billing for scleral and hybrid contact lenses, use HCPCS V2530 or V2531. Not indicating the type of lens (scleral or hybrid), the manufacturer, and the brand of the lens in box 19 will lead to lower reimbursement—V2510 rate. The number of units or lenses will also be needed for the claim.
Irregular astigmatism is not covered.
Note: Visually necessary contact lenses aren’t typically covered for patients who have received elective cosmetic eye surgery (eg, LASIK, PRK, radial keratotomy). Postoperative concerns, however, such as ectasia, scarring, and corneal irregularity that cause vision problems that require correction with contact lenses to provide functional vision are covered under the NCL benefit, so long as patients meet the NCL criteria.
Bills for medically necessary contact lenses are submitted via Eyefinity, and payment can be expected in about 2 weeks.
United Healthcare owns and operates the Spectera Eyecare Network, which bills exams and materials together and has probably the quickest and easiest form to fill out because only the usual and customary fee are on the form that is faxed to the insurance. It is important to bill with the XC modifier. The provider simply submits the exam results, corneal topographies (for irregular corneas), the Health Care Financing Administration form, and sometimes a letter that supports the documentation provided. It usually takes about 2 to 4 weeks for approval and payment.
Below is a list of the conditions that Spectera approves for the use of medically NCLs:
- Irregular corneal astigmatism;
- > 3.50 D acuity <20/70 with glasses and > 20/70 with contact lenses;
- Corneal deformity;
- Corneal opacity;
- Corneal degeneration;
- Corneal ectasia;
- Facial deformity.
A WORTHWHILE INVESTMENT OF TIME AND EFFORT
Medical billing and coding can be tricky because the system is never static. At my office, we wait for full payment from the patient or for the contracted reimbursement from his or her insurance company before dispensing lenses. The more accurate the billing and coding, the sooner the payment can be deposited, allowing lenses to be dispensed in a timely manner.
It is therefore important to understand what each specific insurance carrier defines as medically necessary and what criteria are required to meet medical necessity. You should be able to find this information in a provider manual or by contacting the insurance company to verify that you will be paid for your materials and services. Listening to webinars, attending lectures, and reading relevant journals are some ways to keep up with billing and coding changes that occur over time. Once you start learning about billing and coding it becomes easier, and fitting medically necessary contact lenses can lead to a fulfilling career that is also financially rewarding.
- 1. American Medical Association. CPT 2021 Professional Edition . Salt Lake City, UT: American Medical Association; 2020.
- 2. Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566. Centers for Medicare & Medicaid Services. Accessed May 3, 2021. www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-Instructions.pdf
- 3. Assorted contact lenses HCPCS code range V2500-V2599. Codify by AAPC. Accessed May 3, 2021. www.aapc.com/codes/hcpcs-codes-range/442.
- 4. Welcome to the online claims processing system. EyeMed Vision Care. https://claims.eyemedvisioncare.com/claims/loginForm.emvc. Accessed May 10, 2021.
- 5. Harmon H, Caswell J. Vision insurance FAQ: frame, lens & contact lens benefits. VSP Individual Vision Plans. January 17, 2020. Accessed May 3, 2021.
Optometrist and Owner, Coan Eye Care & Optical Boutique, Ocoee, Florida Member, Modern Optometry Editorial Advisory Board [email protected]; Instagram @coaneyecare Financial disclosure: Speaker (CooperVision)
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What Eyecare (Including LASIK) Does Spectera Vision Cover?
Home / Insurance for Laser Eye Surgery & LASIK / Spectera Vision Insurance Coverage
Spectera Vision Insurance offers comprehensive vision coverage for individuals and their dependents. Services covered by Spectera Vision include:
- Frame benefits
- Contact lens benefits
- Additional glasses
- Lens upgrades
Keep reading as we go into depth on Spectera Vision Insurance and all of its benefits.
Table of Contents
- Spectera Overview
- Eye Surgery & LASIK
Cost of Coverage
The exact services covered by Spectera vary by plan, though all coverage is meant to be comprehensive and provide a number of benefits to Spectera members.
An annual eye exam is the cornerstone of every Spectera vision plan. The Spectera eye exam provides detection, monitoring, and treatment of any vision problems.
Spectera does not provide full coverage for laser eye surgery , though it does grant access to the Laser Vision Network of America, along with member discounts.
The costs of Spectera vision plans vary by plan, so you need to verify your specific vision coverage. The cost of your plan goes toward services, such as member benefits and provider access and choice.
Spectera is proud to offer a nationwide network of eye care providers and retail locations to serve your eye care needs. Through this large network, you can likely find vision services when and where you need them.
Spectera Vision Insurance
Spectera Vision Insurance is owned and operated by UnitedHealthcare. They offer comprehensive vision plans that cover vision needs, ranging from eye exams to glasses and contact lenses.
The goal of Spectera is to provide coverage that makes vision care accessible, affordable, and efficient. The company aims to help its customers save time and money on vision care by finding eye care where and when they need it.
What Is Covered by Spectera?
Spectera vision plans cover a variety of vision services. Services offered include:
- Eye exams. An annual eye exam (minus the copay) is covered to assess for any vision problems.
- Frame benefits. Money from your plan can be used to purchase frames from in-network providers.
- Contact lens benefits. The cost of contact lenses, a fitting, and two follow-up visits is covered (after your copay).
- Additional glasses. Discounts are offered on extra pairs of eyeglasses you purchase.
- Lens upgrades. Many lens options are offered for up to 40 percent off, if they are not covered entirely by your plan.
Spectera vision coverage offers a number of supplementary benefits for network members. Some of these discounts include:
- Laser vision correction discounts offered through the Laser Vision Network of America .
- Reduced pricing on hearing aids through UnitedHealthcare .
- Access to deals on contact lenses.
Spectera Eye Exam
Part of every Spectera vision coverage plan is an annual exam aimed at detecting and monitoring eye problems. According to the Centers for Disease Control and Prevention (CDC), nearly 11 million people living in the United States could have improved vision with the help of proper refractive correction.
Approximately 61 million Americans are at high risk for severe vision loss, but only half of these people report visiting an eye doctor within the past year. Early detection and treatment of vision problems, explains the CDC, are the most effective and affordable approaches to vision care.
To address the need for regular vision care, Spectera offers the Eye Exam Early Detection program. Through annual exams covered by Spectera, eye doctors can assess for:
- Vision disorders.
- Eye muscle coordination.
- Eye diseases.
- Early warning signs of other health conditions.
- By getting regular vision exams, problems can be detected early and treated before they develop into more serious conditions.
Does Spectera Cover Eye Surgery or LASIK?
Spectera Vision coverage provides you access to the Laser Vision Network of America , which is also owned and operated by UnitedHealthcare. Through your Spectera vision plan, you are eligible for discounted laser vision correction procedures, including LASIK. The entire cost of these procedures is not likely to be covered, though your vision plan should help make them much more affordable.
A membership with the Laser Vision Network of America gives you access to over 550 locations across the country that offer laser vision eye surgeries and LASIK. Members and their dependents get a variety of benefits, depending on the provider you choose, such as:
- A free LASIK eye exam.
- 15 percent off standard prices.
- 5 percent off promo prices.
- Lifetime enhancements.
If you don’t achieve the desired results following LASIK, all in-network providers are required to make enhancements or retreatments as necessary for at least the first year following your procedure. There are no benefits given when out-of-network providers are used.
The exact cost of vision coverage varies depending on your specific plan. Each plan typically comes with a copayment and allowance. With the copay, the patient pays a predetermined amount for each eye exam or pair of glasses or contact lenses they buy. The set allowance can be used to help pay for glasses frames and contact lenses.
Spectera prides itself on providing vision plans that offer significant cost savings and excellent member benefits. The cost of your vision coverage goes toward:
- Clear benefits and values.
- Provider access and choice.
- High-quality eye care.
- Eyewear choice and value.
- Convenient customer service.
Those covered by a Spectera vision plan can take advantage of their coverage at many local and national retail locations. These retailers are included in the Spectera vision network:
- Walmart Vision Center
- America’s Best: Contacts & Eyeglasses
- Eyeglass World
- Sam’s Club Optical
In addition to visiting the above stores in person, you can save money by ordering contact lenses online and taking advantage of specific lens discounts, such as progressives or tints. Not all providers and locations offer the same discounts, so it is important to check with your local provider before placing an order.
- Vision Health Initiative: Common Eye Disorders . (September 2015). Centers for Disease Control and Prevention.
- Vision Health Initiative: Fast Facts . (July 2017). Centers for Disease Control and Prevention.
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4 ways to change your thinking-and your reimbursement
A consulting client had a few questions about a patient who came into her office. A contact lens patient wanted to use his Spectera third-party coverage, and the receptionist told him it was no problem.
The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.
The first problem was the office policy of requiring the patient’s Social Security number (SSN) on the intake form, which displeased the patient.
The second problem was how the doctor chose to bill and code the exam. During the course of the exam, the doctor learned that the 74-year-old patient not only had macular degeneration but blepharitis. I’m sure you can see where this is going.
The doctor billed Spectera for a required (in her thinking) dilated exam with a $35 charge for photography, totaling a $110 reimbursement with $65 of that to show up at a later date.
The doctor next gave the patient his Rx and said she’d see him next year for his annual exam.
She wonders what she could have done differently. I found four ways this patient encounter could have gone better.
More from Dr. Nelson: Who is to blame for the public image of optometry?
1. Don’t bother with the SSN
The first piece of advice I offered this doctor is skipping the required patient SSN. This requirement only pisses patients off and makes them think you’re up to something. Unless you absolutely have to have the SSN (for example, if an insurance company requires you to include it), I wouldn't even bring it up. It's just a fight you most likely don't need to have, and it breeds ill will from the beginning. Such a fight may cost you a patient forever over information you don't need, so just take that line off the form.
Next: Always obtain medical carrier information
2. Always obtain medical carrier information
Next, always, always, always obtain the patient's medical insurance (even if you aren’t using it). Inform the patient via the intake form that it is possible his visit will be billed to his medical insurance-you won’t know what’s in the eye until you look. There’s no way on this Earth that a 74-year-old patient’s exam shouldn’t be billed to medical as the primary coverage. The incidence of eye disease in the elderly population is just too high.
That's not to say that you can’t use the Spectera in addition to Medicare to cover the contact lens fit. Just to give some perspective, here is what the examination should have paid:
Spectera CL fee: $75
(Technically, you could charge a 92015, but I’d just consider that part of Spectera’s fees.)
Total billing is $265 vs. the $110 the doctor got paid.
Dropped revenue adds up quickly with differences like this. If you misbilled like this once per day, it makes a yearly $50,000 profit difference. In other words, you'd lose $50,000 income for no reason. That’s with only one of these per day.
Next: Know your third-party contracts
3. Know your third-party contracts
It’s your responsibility to know what your accepted plans cover and what they don’t. After all, you signed the contracts to provide these services at an agreed-upon reimbursement.
Spectera doesn't “require” dilation (unless the contracts have drastically changed their wording)-the contract just says Spectera covers it. Here’s the problem with that: if the patient has medical history which necessitates a dilated fundus exam (such as diabetes, hypertension, high myopia, advanced age, etc.), Spectera should not be billed as the primary insurance. Such cases should always be billed to the medical plan.
It doesn’t matter what Spectera covers because you have a contract with Medicare as well. CMS rules state that you cannot assign benefits (meaning let someone else pay whether it’s Spectera or even allowing the patient to private pay) for Medicare-covered services. An eye exam in which the patient has cataracts, macular degeneration, diabetes, hypertension, blepharitis, or any other medical condition is most definitely a Medicare-covered service.
More blogs: ICD-10: Not quite the end of days
4. Schedule appropriate follow-up visits
Following a patient appropriately, especially an elderly patient, is a key part of our jobs.
The patient in this example has macular degeneration and blepharitis. Those conditions alone-all covered by Medicare-should warrant at least two additional yearly visits to properly monitor. If the patient had secondary medical insurance, he likely would have had zero out-of-pocket expenses.
Next: Change your thinking-and your billing
Change your thinking-and your billing
We have to get out of the typical OD mindset in which we’re performing quickie vision exams, handing patients a piece of paper, and telling them, “See ya next year.”
Let's take just this one patient as our example.
On this visit alone, the doctor lost $155. I would have seen the patient at least two more times this year to follow up for the blepharitis and age-related macular degeneration. I might also include photos at the six-month mark if I see clinical changes. Those two visits would run somewhere in the neighborhood of $65 for a 92012, so a minimum of $130 additional exam fees from this one patient.
So, this didn't lose $155-she actually lost $285. That gets pricey if it becomes a regular billing practice.
More from Dr. Nelson: OD calls BS on OMD's fearmongering
This principle holds true for most ocular conditions. Glaucoma suspects, diabetics, allergy patients, dry eye-all of these patients should be both billed to medical and scheduled appropriate follow-up through the year if you intent to provide a level of care commensurate with the conditions these patients have.
As an aside, be careful if you are charging a certain fee for screening photos. Make sure that you document that you are billing only for the technical component of the photography. Remember that third-party payers cover a combined reimbursement for the technical component and the professional component, the latter including a separate interpretation and report.
Third-party payers don’t care what you charge as long as your fee is consistent for covered patients as well as private-pay patients-meaning you aren’t charging covered patients more.
So, ensure that your documentation shows that you aren’t billing a full 99250 and charging only for the technical component, not the professional interpretation. Semantics is more important than you think with third-party payers. Take the extra few minutes to get it right so you aren’t inadvertently reducing the fees to which you’re entitled.
Remember these four changes to better improve your patient care and get paid for the services you’re providing.
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THE BUSINESS OF CONTACT LENSES
Vision Care Plans
FOR YEARS, I have maintained the Coding and Billing module of the GP Lens Institute (GPLI) website. One of my duties is to do a yearly webinar to update prescribers and billers on coding and billing.
However, I recently had to do an update after a webinar because there were enough changes in vision care plans’ (VCPs’) visually necessary contact lens benefits that we had to talk about those changes.
First, over the past few years there has been significant consolidation of the VCP market. This consolidation is part and parcel of the continuing vertical integration of the vision care markets. For several years, EyeMed and Aetna Vision have been associated as independent contractors. UnitedHealthcare purchased Spectera Vision in 2001. More recently, Versant Health acquired the Superior Vison and Davis Vision plans.
For many years, Vision Service Plans (VSP) and EyeMed had significantly higher reimbursements for necessary contact lenses, but that has changed recently. Beginning in January 2023, Spectera Vision and Superior Vision totally revamped their visually necessary lens policies and reimbursements.
Before I begin, I strongly advise each prescriber and biller to read the visually necessary contact lens policies of every carrier with which they contract. This read should take place annually.
My office annually copies the online policies of these VCPs into a PDF under the Fair Use Doctrine, and I place these documents on the desktops in the exam room and administrative area computers so that we can look up the polices quickly and authoritatively.
Each of the VCPs has a limited data set of qualified conditions that have per se coverage under their respective necessary policies. There is significant correlation between the VCPs, but there are differences of which eyecare providers must be aware.
First, VSP’s and EyeMed’s policies are roughly the same as they have been in previous years. For VSP, the biggest change is the addition of the following: “Corneal Refractive Therapy, Orthokeratology, and contact lenses for Myopia Management are not covered under necessary contacts, covered contact lenses or the VSP Elements Plan. Patients can use their elective contact lenses allowance towards the cost of Corneal Refractive Therapy, Orthokeratology, or Myopia Management contact lens materials only. The Contact Lens Fitting and Evaluation portion of the treatment is a private transaction between you and the patient.”
It is important to know that the VSP benefit only covers services for the first 90 days of care. “Any fitting fees incurred after the initial 90-day period are considered a private matter between you and the patient.”
EyeMed prescribers and billers are advised to read up on the delineation between mild/emerging and moderate/severe keratoconus. Further, read up on the various carrier-specific EyeMed code modifiers. EyeMed has seven code modifiers for all of the qualifying criteria except keratoconus, which has its own Current Procedural Terminology (CPT) code.
Make sure that for the mild/emerging keratoconus patient to use the H18.61x “Stable” codes, and for the moderate/severe keratoconus patient use the H18.62x “Unstable” codes.
Spectera, too, has a limited data set of covered conditions, but they only have a single code modifier, -XC, for all necessary prescribing. Make sure to append your prescribing codes accordingly.
Superior Vision, like Spectera, has a single modifier, -KX, to delineate necessary prescribing. Also, Superior lists myopia management as a covered service and Superior now has an online portal for submitting claims.
Do your homework regarding these changes and follow the rules! CLS
Dr. Newman has been in private practice in Dallas since 1986, specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a diplomate in the American Academy of Optometry and a consultant or advisor to the GP Lens Institute, Avellino, Novartis, and the Texas Optometry Board. Contact him at [email protected] .
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