Paul Sanchez
Scleral lenses are large-diameter contact lenses that are rigid, gas-permeable, and offer improved comfort and clear vision. They are often used to treat corneal irregularities and dry eye syndrome. The cost of scleral lenses can be high, so many people with eye problems wonder whether their medical insurance will cover the cost of these lenses. In general, medical insurance plans do not cover scleral lenses, but vision insurance plans may cover some or all of the cost, especially if the lenses are deemed medically necessary.
| Characteristics | Values |
|---|---|
| Medical insurance coverage for scleral lenses | In many cases, medical insurance will cover the cost of scleral lenses, especially if you have a medical eye condition such as keratoconus. |
| Vision insurance coverage for scleral lenses | Vision insurance plans may also cover scleral lenses, but reimbursement rates can be low. Specific plans like VSP or EyeMed are known to provide coverage for medically necessary cases. |
| Factors influencing coverage | Coverage depends on the insurance company, with some covering eye exams and fittings but not the lenses themselves, and others covering a portion or all of the lens cost if other treatments have been tried first. |
| Steps to determine coverage | Consult with your insurance provider and eye doctor to understand your coverage and total cost. Your doctor may need to provide a letter of medical necessity to the insurance company. |
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What You'll Learn
Vision insurance plans may cover scleral lenses
It is important to note that vision insurance plans primarily aim to reduce the costs associated with eyewear purchases, including contact lenses. While some plans include coverage for medically necessary contact lenses, this is not always the case. To ensure coverage, it is advisable to confirm with your insurance provider and eye doctor whether scleral lenses are considered a covered service within their practice.
In some instances, insurance companies may request additional information or a consultation with your doctor to understand your medical eye condition and the necessity of scleral lenses. With proper documentation and support from your doctor, you may increase your chances of obtaining coverage for scleral lenses through your vision insurance plan.
Furthermore, vision insurance policies can vary significantly, and it is essential to carefully review the specifics of your plan. The level of coverage for scleral lenses may differ based on factors such as the presence of a medical eye condition, the availability of alternative treatment options, and the overall cost of the lenses and associated services.
To maximize your insurance benefits, it is recommended to explore options such as enrolling in specialized vision plans like EyeMed or VSP, which have a track record of providing more comprehensive coverage for scleral lenses. Additionally, utilizing Healthcare Savings Accounts (HSA) or Flexible Savings Accounts (FSA) can help cover any out-of-pocket expenses related to scleral lenses that may not be fully covered by your insurance plan.
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Medical insurance may cover scleral lenses
Firstly, it's important to understand the difference between medical insurance and vision insurance. Medical insurance typically covers eye exams, diagnostic measurements, and medical eye conditions. In contrast, vision insurance plans are designed to reduce the costs of eyewear purchases, including contact lenses and frames.
When it comes to scleral lenses, coverage by medical insurance varies. Some medical insurance plans may cover the cost of the lenses, especially if you have a medical eye condition such as keratoconus, corneal scarring, corneal transplants, RK scarring, or post-LASIK issues. In these cases, a doctor may need to provide a letter of medical necessity to your insurance company, explaining why scleral lenses are required to improve your vision. However, it's worth noting that not all medical insurance plans will cover scleral lenses, even if they are medically necessary. Some plans may have specific exclusions for refractive corrections or may only cover the cost of routine eye examinations and testing for conditions like keratoconus.
Vision insurance plans, on the other hand, are more likely to cover scleral lenses when they are deemed medically necessary. Plans such as VSP (Vision Service Plan) and EyeMed are known to provide coverage for scleral lenses when prescribed for keratoconus and other corneal disorders. However, it's important to carefully review your specific vision insurance plan, as coverage can vary significantly, and some plans may not include the medically necessary add-on.
To determine if your medical or vision insurance covers scleral lenses, it is recommended to consult with your insurance provider and eye doctor. They can provide specific details about your coverage and help you understand the cost you may be responsible for. Additionally, your doctor can work with your insurance company to increase the likelihood of coverage by explaining the medical necessity of scleral lenses for your particular case.
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Insurance companies may request to speak with your doctor
If your doctor deems scleral lenses to be medically necessary for you, they may write a letter to your insurance company explaining your medical eye condition and why you need scleral lenses. This could be due to a number of reasons, including keratoconus, corneal scarring, corneal transplants, RK scarring, or post-LASIK eye surgery.
In some cases, your insurance company may request to speak with your doctor directly to discuss your condition and the necessity of scleral lenses. This could be to better understand your diagnosis and the treatment options available. During this discussion, your doctor can provide your insurance company with your diagnosis, ICD-10 codes, and CPT and V codes to make a case for why scleral lenses should be covered.
By involving your doctor and providing detailed medical information, you can increase your chances of receiving coverage or reimbursement for scleral lenses. This collaborative effort ensures that your insurance company has a clear understanding of your medical needs and can make an informed decision regarding coverage.
It is important to note that insurance coverage for scleral lenses can vary depending on your specific plan and insurance provider. Some insurance companies may cover the cost of the lenses but not the associated services, such as fitting and follow-up care. Other insurance plans may provide better reimbursement rates for scleral lenses, making it more feasible for your doctor to accept that insurance. Therefore, it is always a good idea to consult with your insurance provider and review the specific details of your plan to understand what is covered and what you may need to pay out-of-pocket.
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Some insurance companies reimburse poorly for scleral lenses
While medical and vision insurance may cover the cost of scleral lenses, some insurance companies reimburse poorly for them. This is because scleral lenses are typically 10 times more expensive than traditional gas-permeable lenses, and many insurance companies reimburse less than the cost of the lens. For example, if a scleral lens costs an eye doctor $500, but the insurance company only reimburses $100, the doctor would be fitting the lenses at a loss. As a result, many doctors cannot accept vision or medical insurance plans for scleral lens fittings.
Some insurance companies, such as VSP or EyeMed, reimburse eye doctors well for scleral lenses, and many offices accept this insurance for scleral lenses. However, other insurance plans reimburse eye doctors poorly for scleral lens fittings, making it unrealistic to expect doctors to fit patients with these lenses. In these cases, patients are often responsible for paying for the fitting, dispense, and follow-up care.
To improve your chances of getting insurance coverage for scleral lenses, you can ask your doctor to write a letter of medical necessity. This letter explains to the insurance company why the patient needs scleral lenses, usually due to a medical eye condition such as keratoconus, corneal scarring, corneal transplants, RK scarring, or extreme dry eye. Your doctor can also provide a list of diagnosis codes, ICD-10 codes, CPT codes, and V codes, along with the pricing for each service, to help make a case for insurance coverage.
Ultimately, the coverage provided by vision insurance for scleral lenses is never concrete, and the experience of each patient may vary. It is recommended that patients schedule a consultation with an eye doctor to assess their visual needs and budget to determine if scleral lenses are a suitable option.
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HSA and FSA funds can be used for out-of-pocket costs
If you have a medical eye condition, such as keratoconus, corneal scarring, corneal transplants, RK scarring, or post-LASIK, your insurance company is more likely to cover the cost of scleral lenses. Both vision insurance and medical insurance may cover scleral lenses. However, if you have a non-medical eye condition such as myopia, hyperopia, or astigmatism, your insurance will probably not cover the cost. In such cases, you can use your HSA or FSA funds to cover the out-of-pocket costs.
HSA (Health Savings Account) and FSA (Flexible Spending Account) are programs offered by employers that allow you to set aside pre-tax funds for eligible healthcare expenses, including prescription eyewear and contact lenses. You can use your HSA or FSA to cover the cost of prescription glasses, including designer glasses, and contact lenses. You can also use these funds to pay for an eye exam to determine your prescription.
FSA funds must be used by the end of each calendar year (December 31); otherwise, you lose the money. HSA funds, on the other hand, roll over indefinitely and can be used for healthcare expenses in retirement. If you have an FSA, it is important to plan ahead and identify eligible expenses to make the most of your funds before the deadline.
You can use your HSA/FSA debit card at your optometrist or ophthalmologist's office, or at any retailer that accepts these cards, to pay for eligible expenses directly. Keep your receipts, as you will need them to get reimbursement from your FSA if you pay out of pocket. You will also need your receipts to prove HSA- and FSA-eligible expenses in case of an IRS audit.
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Frequently asked questions
It depends on your insurance company and your specific plan. Some insurance companies do cover the cost of scleral lenses, especially if you have a medical eye condition such as keratoconus. In some cases, insurance companies will only cover the cost of the lenses and not any associated services.
Scleral lenses are rigid gas permeable lenses with an extra-wide diameter that vaults over the entire cornea. They are custom-fit to your eye and are perfect for those with hard-to-fit eyes, astigmatism, keratoconus, severe dry eye, or for those seeking more comfort when wearing contact lenses.
You can start by checking with your doctor's office to see how much you would be responsible for. Your doctor may also be able to help you get a portion or all of the scleral lens fitting covered by writing a letter of medical necessity to your insurance company.
A letter of medical necessity is a letter from your doctor to your insurance company explaining your medical eye condition and why scleral lenses are necessary for you.
Vision insurance plans such as EyeMed, VSP, and Davis Vision typically cover most of the cost of scleral lenses when prescribed for keratoconus and other corneal disorders.
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