Standard Lenses: Insurance Coverage Basics

When it comes to insurance coverage for eyeglasses and contact lenses, it's important to understand the distinction between medically necessary and elective lenses. While eyeglasses are typically considered the standard and most cost-effective treatment option, contact lenses can also be deemed medically necessary in certain cases. This is when specific medical conditions hinder vision correction through regular eyeglasses, and contact lenses become the accepted standard of treatment. For instance, conditions such as Aphakia, Anisometrophia, or Keratoconus may require the use of medically necessary contact lenses. On the other hand, elective contact lenses are chosen by individuals who prefer them over eyeglasses for cosmetic purposes. While Medicare Part B covers eyeglasses or contact lenses after cataract surgery, other plans may offer different benefits, so it's essential to understand the specifics of your insurance coverage.

Medicare Part B covers standard lenses after cataract surgery

Medicare Part B, also known as Medical Insurance, does not typically cover eyeglasses or contact lenses. However, it makes an exception for cataract surgery patients who require an intraocular lens implant. This coverage is limited to a single pair of glasses with standard frames or a single set of contact lenses. Patients are responsible for any additional costs for upgraded frames.

It is important to note that Medicare will only cover lenses from a supplier enrolled in Medicare. Patients are advised to consult their doctor or healthcare provider to understand the specific costs they may owe, as this can vary depending on other insurance coverage, the doctor's charges, the facility, and other factors.

Furthermore, some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare does not, such as vision, hearing, or dental coverage. Thus, it is recommended to contact the plan provider for detailed information about their specific coverage.

In summary, while Medicare Part B does not typically cover lenses, it makes an exception for patients who have undergone approved cataract surgery with an intraocular lens implant. This coverage includes standard lenses, and patients may need to pay additional costs for upgraded options or frames.

Non-elective contact lenses are prescribed for certain medical conditions

Non-elective contact lenses, also known as medically necessary contact lenses, are prescribed by an optometrist when certain medical conditions hinder vision correction through regular eyeglasses. In such cases, contact lenses are the accepted standard of treatment.

Medically necessary contact lenses are not elective and are often the only treatment option that provides optimal vision for patients with ocular conditions. These include conditions such as keratoconus, an eye disease that causes structural damage to the cornea, changing it from a normal, round shape to a bulging, cone shape. Other conditions include Sjogren's Syndrome, a systemic condition that causes severe dry eye, and aphakia, the removal or absence of the lens of the eye(s) due to surgery, injury, or abnormality.

Medically necessary contact lenses can be soft, disposable, or extended wear, or they may be hard or rigid gas permeable. Hybrid contact lenses, which consist of rigid gas permeable lenses with a soft lens skirt, are also an option.

While there is no universal definition of what constitutes medically necessary contact lenses, they are generally recognised as a medical device by the FDA. When billing for medically necessary contact lenses, specific codes such as CPT and HCPCS codes are used.

Medicare Part B (Medical Insurance) covers one set of contact lenses after each approved cataract surgery that implants an intraocular lens. However, it's important to note that Medicare doesn't usually cover eyeglasses or contact lenses.

VSP vision insurance offers savings on frames and lenses

VSP vision insurance offers a range of savings on frames and lenses, with different plans available depending on your needs.

Standard Option Plan

The Standard Option plan includes a $200 frame allowance on featured frame brands at Premier Edge locations or any frame at Visionworks, or a $150 frame allowance at other in-network providers. This plan also covers single-vision, lined bifocal, and lined trifocal lenses.

High Option Plan

The High Option plan includes a $250 frame allowance on featured frame brands at Premier Edge locations or any frame at Visionworks, or a $200 frame allowance at other in-network providers.

EasyOptions Plan

The EasyOptions plan offers a higher frame allowance of $230 and also includes fully covered progressive lenses.

Lens Enhancements

VSP members can enjoy savings of up to 30% on lens enhancements such as anti-glare, scratch-resistant, and progressive lenses when purchased through a VSP network doctor.

Additional Pairs

VSP members can also save 20% on additional pairs of glasses or sunglasses, including lens enhancements, from a VSP network doctor within 12 months of their last eye exam.

Out-of-Network Reimbursement

If you choose to see an out-of-network provider, you can file an out-of-network claim and receive reimbursement for 75% of the billed charges.

Online Shopping

VSP members can also use their benefits online at Eyeconic, the official VSP online store, to purchase contacts, glasses, and sunglasses.

With VSP vision insurance, you can access high-quality eyewear at affordable prices and save on frames and lenses.

Elective contact lenses are considered cosmetic

In the United States, contact lenses are considered medical devices by the FDA and cannot be obtained legally without a prescription. This is true whether they are used for vision correction or cosmetic purposes, such as changing eye colour.

The distinction between elective and non-elective (or medically necessary) contact lenses is important when it comes to insurance coverage. Non-elective contact lenses are prescribed by an optometrist and are often the only treatment option for patients with certain ocular conditions, such as keratoconus or severe dry eye caused by systemic conditions like Sjogren's Syndrome. These lenses are recognised as a medical device and are not considered cosmetic.

Medicare, for example, does not usually cover eyeglasses or contact lenses. However, Medicare Part B (Medical Insurance) covers one pair of eyeglasses with standard frames or one set of contact lenses after each approved cataract surgery that implants an intraocular lens. In this case, the contact lenses are considered medically necessary following a specific surgical procedure and are not considered cosmetic.

Vision insurance plans, such as VSP, also offer coverage for contact lenses, but it is important to understand the specific requirements and parameters of each plan. VSP, for instance, provides an elective contact lens allowance, where instead of buying glasses (frames and lenses), one can purchase new contact lenses every 12 months without a copay.

It is worth noting that the definition of medically necessary contact lenses varies across different vision and health plans, and it is essential to consult with an eye care professional to determine eligibility and coverage.

Medically necessary contact lenses are recognised as a medical device by the FDA

Contact lenses are recognised as a medical device by the FDA and are therefore regulated by the Federal Food, Drug, and Cosmetic Act. This means that a valid prescription is required to purchase contact lenses.

The FDA classifies contact lenses as either Class II or Class III medical devices. Regular-wear contact lenses are Class II devices, meaning they pose a moderate risk to health when used without physician oversight. Lenses that can be worn overnight or on an extended-wear schedule are Class III devices, indicating a higher risk to health and safety without appropriate physician oversight.

Medically necessary contact lenses are not elective and are often the only treatment option for patients with ocular conditions such as keratoconus or systemic conditions like Sjogren's Syndrome, which can cause severe dry eye. They can improve visual acuity and reduce distortion in ways that glasses cannot, ultimately enhancing the patient's quality of life.

There is no universal definition of what constitutes medically necessary contact lenses, as this varies across different vision and health plans. However, medically necessary contact lenses can range from soft contact lenses (including disposable or extended-wear lenses) to hard lenses (such as rigid gas permeables or scleral lenses). Hybrid contact lenses, which consist of rigid gas permeables with a soft lens skirt, are also an option for vision correction.

When billing for medically necessary contact lenses, it is important to use the correct CPT codes (92071, 92072, and 92313) and select the proper code for the specific type of contact lens the patient is being fitted for. Proper testing, diagnosis, and billing codes are crucial for eyecare providers to ensure that patients have access to the treatment options they need.

Frequently asked questions