Alyssa Lane
Whether or not medical insurance covers keratoconus depends on the type of insurance plan and the state, as well as the severity of the condition. Vision plans such as Vision Service Plan (VSP) and EyeMed Vision Care are supplemental to standard health insurance and can help cover the cost of treating keratoconus. However, they typically do not cover eye surgery or specialised contact lenses. Medical insurance, on the other hand, can cover corneal cross-linking surgery and corneal transplantation for advanced keratoconus, but the coverage varies among insurance providers.
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What You'll Learn
Corneal cross-linking surgery
The procedure itself is painless and takes about an hour to complete per eye. It is an outpatient procedure and is performed on one eye at a time. Anesthetic eye drops are used to avoid any discomfort for the patient. There are two primary types of corneal cross-linking procedures: epithelium-off cross-linking and epithelium-on cross-linking (also known as transepithelial cross-linking). During the epithelium-off procedure, the thin outer layer of the cornea (epithelium) is removed, while in the epithelium-on procedure, this layer remains intact.
Before the surgery, an eye doctor will evaluate your vision and eye health, measure the thickness of your cornea, and determine if you are a suitable candidate for the procedure. They will then perform detailed mapping of your cornea to prepare for the surgery and provide you with instructions to follow. On the day of the surgery, it is recommended that you do not apply any eye makeup, perfume, or aftershave. It is also advisable to arrange for someone to drive you home afterward.
During the procedure, specialty formulated riboflavin (vitamin B) eye drops are applied to the surface of the eye to help the cornea absorb light. After about 30 minutes, the patient lies back and looks up at a light. A controlled exposure of ultraviolet light is then performed. The entire treatment takes about 60-90 minutes.
After the procedure, topical antibiotic and anti-inflammatory drops may be prescribed, and a bandage contact lens will be placed on the eye to aid in the healing process. It is normal to experience some eye discomfort, blurred vision, and sensitivity to light during the recovery process. The bandage contact lens is removed once the surface has fully healed, which usually takes about 3 months.
Regarding insurance coverage, medical insurance can defray the cost of corneal cross-linking surgery, with upwards of 95% of medical insurances covering this procedure. However, some sources indicate that cross-linking is not covered by most health insurance at this time, and coverage is being debated. Vision plans like Vision Service Plan (VSP) and EyeMed Vision Care can provide coverage for medically necessary contact lenses, but they typically do not cover corneal cross-linking surgery. It is important to note that insurance coverage can vary from plan to plan and from state to state, so it is always best to check with your insurance provider for specific details.
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Corneal transplantation
There are two types of corneal transplants commonly used to restore a normal corneal shape in advanced cases of keratoconus: PK and deep anterior lamellar keratoplasty (DALK). In PK, the full thickness of the front of the eye wall is replaced by a disc-shaped piece of donor corneal tissue, which is sewn into place. DALK, on the other hand, involves selectively replacing the abnormally shaped front 95% of the cornea while leaving the thin back layers, such as the corneal endothelium and Descemet's membrane, intact. DALK reduces the risk of transplant rejection and the likelihood of future replacement but is technically demanding. In some cases, surgeons may intend to perform DALK but convert the operation to PK during surgery if the thin back layers of the cornea cannot be preserved.
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Vision benefit plans
Qualifying for medically necessary contact lenses varies from one vision plan to another. For example, with most EyeMed plans and Medical Eye Services, the severity of your keratoconus must meet specific criteria. In contrast, with most VSP coverage, even the mildest cases of keratoconus qualify. It is important to be evaluated in a practice familiar with the nuances of necessary contact lens authorizations and navigating what is covered.
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Contact lenses
Qualifying for medically necessary contact lenses varies among vision plans. For example, EyeMed plans and Medical Eye Services require that the severity of keratoconus meets specific criteria, while VSP coverage typically does not consider the severity of the condition when determining coverage. It is important to note that even if covered, medically necessary contact lenses may not be fully covered, and patients may still incur significant out-of-pocket costs. Additionally, vision plans may have co-payments for services and contact lenses.
When considering insurance coverage for keratoconus, it is recommended to select an eye doctor first and then check if they are in-network with your insurance or vision plan. Some networks may not offer adequate reimbursement for providers to deliver quality care, potentially resulting in less experienced doctors or outdated technology. Individual plans, such as VSP and EyeMed Individual Plans, generally do not include necessary contact lens provisions, as paying out more than what is funded through premiums would make the plan financially insolvent.
To determine if your insurance covers contact lenses for keratoconus, it is advisable to review your plan's Medical Policy or Covered Services section. Some insurers, like Aetna, consider services related to the evaluation of keratoconus, including the fitting of contact lenses or scleral lenses, as medically necessary. In contrast, others, like Blue Cross of Kansas, do not allow standard soft contacts for keratoconus management, as they are intended to improve vision rather than alter the disease's progression.
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Health insurance plans
Vision Insurance Plans
Vision Service Plan (VSP) and EyeMed are examples of vision insurance plans that can be purchased as a supplement to your standard health insurance. These plans often provide coverage for routine eye examinations, testing, and diagnosis of keratoconus. In some cases, they may also help pay for the cost of treatment, including specialty contact lenses or corneal cross-linking surgery. However, it's important to note that vision insurance plans typically do not cover the full cost of treatment and may have specific criteria for coverage.
Standard Health Insurance
Carriers such as Blue Cross Blue Shield, Medica, and United Health Care often cover the cost of routine eye examinations and testing required for diagnosing keratoconus. In advanced cases of keratoconus, standard health insurance plans may also cover surgical treatments, such as corneal transplantation. However, standard health insurance rarely covers glasses or contact lenses, even if they are medically necessary.
Healthcare Savings Accounts (HSA) and Flexible Savings Accounts (FSA)
These accounts allow you to set aside pre-tax funds for keratoconus-related expenses that may not be covered by your health insurance plan. This can help you manage the out-of-pocket costs associated with treatments or procedures that are not fully covered by insurance.
Corneal Cross-Linking Coverage
Corneal cross-linking is a procedure used to treat keratoconus and prevent its progression. While it is an effective treatment approved by the FDA, it is not typically covered by most health insurance plans. However, there are exceptions, and some insurance companies, such as Aetna, Cigna, and Moda Health, specifically mention coverage for epithelium-off cross-linking. This procedure can cost between $2,500 and $4,000 per eye, so it is important to understand your insurance coverage before undergoing this treatment.
Contact Lenses Coverage
Specialty contact lenses, such as scleral or rigid gas permeable lenses, can be prescribed for keratoconus. However, medical insurance rarely covers these lenses, considering them cosmetic rather than medically necessary. In some cases, vision insurance plans may provide better coverage for contact lenses, but it is important to review the specific criteria and limitations of your plan.
In summary, health insurance plans can vary significantly in their coverage of keratoconus treatment. It is essential to carefully review your insurance plan's details and consult with your doctor to understand what treatments and procedures are covered and to what extent.
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Frequently asked questions
Medical insurance rarely covers corneal cross-linking, a procedure used to treat keratoconus. However, coverage is currently being debated and is growing each month.
Yes, most medical insurances cover the cost of corneal transplantation after all other treatment options have been exhausted.
Vision plans such as Vision Service Plan (VSP) and EyeMed Vision Care can help pay for the cost of treating keratoconus. However, they do not usually cover medically necessary contact lenses.
Medicare covers appointments for diagnosing and testing for keratoconus but does not cover the appointment for lens fitting or the lenses themselves.
