Should Eye Care Be Covered By Basic Health Insurance?

Updated on January 18, 2022

We all need health coverage; that much is clear. Health insurance is a fantastic resource; you get to save thousands of dollars on medical costs when you fall ill. But basic health insurance is limited, and there is only so much it can cover. So what happens when you have, say, an eye problem? You go to the eye doctor. But who picks up the tab? 

Eye checkups, glasses, and contact lenses do cost money. Eyecare is not covered by basic health insurance, and you will have to pay a small fortune in insurance premiums to include it in your health coverage. So most people would rather pay out of pocket or skip seeing an eye specialist, even when they sense all is not well with their vision. This situation cannot be right; it would mean that people are ignoring their eye health and risking blindness because they cannot afford vision care. 

Logically, those who would be most affected by this high cost of vision insurance are the economically-disadvantaged – people who probably have to deal with other challenges and rely on basic insurance for their health needs. This gap further widens the inequity in society as these low-income earners will struggle to get doctors’ appointments since most eye care providers will not accept basic health insurance. 

Why Is Eye Care Not Included in Basic Health Insurance?

First, what does basic health insurance cover?

What you get as basic health insurance depends on several factors. US citizens pay widely varying premiums on medical coverage depending on their states of residence, income level, age, healthcare plan, insurance provider, employer size, among other factors.

Eyecare is technically covered by basic insurance. However, it is important to know what aspects of eye care basic insurance covers. This is important because while eye care providers know about insurance plans and what they cover, they are not responsible for knowing the specific details of a patient’s policy. 

Basic health insurance covers those parts of eye care considered medical necessities. They include: 

  • Comprehensive eye checks
  • Diabetes eye exams
  • Monitoring and treatment of glaucoma 
  • Monitoring cataract development
  • Management and treatment of macular degeneration
  • Monitoring and treatment of glaucoma
  • Emergency visit for vision loss due to a medical condition
  • Examination of patients on medications with potential side effects

States must adhere to the set guidelines, and examinations must meet specific standards. For people above 21, the examination frequency depends on the state of residence. Basic insurance covers eye examinations every two to three years on average. 

Finding out why eye care is not part of basic health insurance is not a straightforward matter. Basic health insurance does not cover eye care because of the differences between optometry and ophthalmology.

The optometrist is the professional who examines your eyes for problems and tells you whether you need glasses, contacts, or something else. An optometrist can also treat uncomplicated eye issues. They are the ones you go to see for your annual or biennial eye exams. 

Most people cannot tell the difference between an optometrist and an ophthalmologist. The optometrist sends you to the ophthalmologist if your case is complicated. The ophthalmologist is the person you go to when you need specialized care like glaucoma or cataract surgery. 

Your basic health insurance may cover some parts of your visit to the optometrist. But you will need vision insurance or special premiums to see an ophthalmologist. If you do not see an optometrist, you may miss an eye problem till it becomes severe. Unfortunately, this is the case for many people due to basic health insurance limitations. 

Why Doesn’t Basic Insurance Cover All Aspects of Eye Care? 

The optometry/ophthalmology dichotomy means that both groups of professionals are considered to be providing different services. So, they have different insurance payment structures. However, citizens can opt for vision coverage, an optional health insurance service that covers visits to the optometrist. 

What Does Vision Coverage Include? 

The specific details vary by state, but vision insurance generally covers the following:

  • Early and periodic screening, diagnostic, and treatment benefits for children under 21.
  • Medically necessary eye care, including eye injuries, symptoms of illness, disease, and injury. 
  • Medically necessary eye exams
  • Eyeglasses and basic frames needed to correct vision problems caused by accidents or disease.
  • Contact lenses needed to correct vision problems caused by accidents or disease. 

Why Should Basic Insurance Cover Eye Care? 

According to this study, nearly half of Americans opt against paying for vision coverage because of cost and lack of insurance. So if the need to see an optometrist arises, they have to foot the expenses out-of-pocket. These people will never visit an optometrist unless their condition compels them otherwise. 

The problem with refusing to go for regular eye exams is that they have to live with underlying eye conditions that routine eye exams could detect. Many people also live with vision problems that could easily be corrected by contact lenses or eyeglasses. Many people who do not have vision coverage suffer degenerative diseases like cataracts and glaucoma and are at higher risk of vision loss as they grow older

Those unable to get vision coverage and proper eye care do not only represent those of a lower socioeconomic class. This research on insurance coverage disparities in glaucoma care, a condition that triggers eye care insurance benefits, also points to a racial and ethnic disparity. The study found the odds of white people on basic health insurance having no glaucoma test to be 198% greater than those with premium insurance plans. This disparity is higher for minority ethnic groups; African American people on basic health insurance have a 291% chance of not being tested for glaucoma than those with vision coverage. 

Final Words

The thought that socioeconomic and racial inequities can affect access to eye care and potentially cause vision loss is alarming. People who have basic health insurance would want to seek out eye care providers who accept them. However, government and relevant agencies should consider enacting laws that broaden the scope of basic health insurance.

The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.