For both children and adults, regular exams may reveal potential medical issues, such as early warning signs for diabetes.[0] And as you age, you may need more frequent vision exams.
The Mayo Clinic recommends the following frequency for eye exams:[1]
- Age 20-39 – every 5-10 years
- Age 40-54 – every 2-4 years
- Age 55-64 – every 1-3 years
- Age 65+ – every 1-2 years
So, does the Affordable Care Act (also referred to as “Obamacare”) provide coverage for things like eye exams? And if not, where and how do you get vision coverage?
Keep reading to find out:
- Where to get vision coverage for kids
- Where adults can go to get vision benefits
- Where seniors can go for vision insurance
Where to Get Pediatric Vision Coverage
When it comes to pediatric vision coverage, that is, vision benefits or discounts for kids, you generally have four options outside of your employer’s group benefits:
- ACA health plans (as an essential health benefit)
- Medicaid/CHIP if you qualify
- Private vision insurance
- Vision discount plans
ACA Health Plans
For children 18 and under, vision coverage is considered an essential health benefit and is included in all ACA-compliant individual major medical plans, both on and off the federal exchange.[2]
Vision screening for children is considered preventive care, which means it’s a covered health benefit in an ACA-compliant plan, but all other vision-related services may include copays, be counted towards the deductible or subject to coinsurance.[3]
Remember, essential health benefits are outlined in the ACA, but the actual services that comprise the benefits are based on each state’s “benchmark” ACA plan. The services included in Obamacare pediatric vision coverage in Alabama may look different from the coverage in North Dakota, for example.
Depending on your state, your child could have some level of coverage for eye exams and glasses or contact lenses to correct vision problems.[4]
If a state’s benchmark plan does not include pediatric vision services, those benefits are provided by either the Federal Employee Dental and Vision Insurance Plan (FEDVIP) or the state’s Children’s Health Insurance Program (CHIP).[5]
Most states use FEDVIP, which covers an annual eye exam and one pair of eyeglasses per year. Some states use CHIP to cover annual eye exams and, with some limitations, corrective lenses.[6]
Shop the ACA Exchange during open enrollment or a qualifying special enrollment period.
Medicaid or CHIP
If your child qualifies, they may be able to obtain vision benefits through either CHIP, Medicaid or a combination program.[7]
Per the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, Medicaid covers diagnosis and treatment for vision problems, including eyeglasses for children under 21. Individual states determine how frequently these services are provided.[8]
You must qualify to enroll in Medicaid and CHIP based on your household income.
Where to Get Adult Vision Coverage
When it comes to vision coverage, adults have three options outside of employer-provided benefits:
- Embedded with an ACA plan (if available)
- Medicaid
- Private vision insurance
- Vision discount plans
Embedded with an ACA Plan
ACA Marketplace health plans do not have to offer vision coverage to adults, but adults can get vision coverage on the federal exchange as part of their major medical plan if it’s included in a plan’s benefits.[9]
Stand-alone vision insurance plans are not available directly from the federal or state marketplaces. So if there are no ACA plans available that include vision benefits (or no plans that fit your needs) you’ll have to look towards a private health insurance provider.[10]
Medicaid
If you qualify for Medicaid, you may be able to obtain coverage for optometry services and eyeglasses depending on your state.[11]
Where to Get Vision Coverage for Seniors
Even if you’ve had perfect eyesight throughout your life, as you age, you may begin to experience vision issues. Also, conditions such as diabetic retinopathy, macular degeneration, and cataracts can develop as we age, so vision care is important.[12]
Seniors have the following options for vision coverage outside of an employer’s benefits:
- Medicare
- Private vision insurance
- Vision discount plans
Medicare
Traditional Medicare (Part A and Part B) typically does not cover eyeglasses, contact lenses or routine eye exams. However, Medicare Part B generally covers preventive and diagnostic eye exams for conditions including diabetes, glaucoma and macular degeneration.[13]
Some Medicare Advantage plans offer more vision coverage. A Medicare Advantage plan may cover:[14]
- One new pair of eyeglasses every two years
- Routine eye exams and other services not covered by traditional Medicare
- Contact lenses
- Eyeglass frames and upgrades
Individual Vision Insurance
Individual vision insurance plans for just you or your whole family are available in the private market.
With a vision benefits plan, you pay a monthly or annual premium based on a benefits level that you select. Benefits typically have an annual maximum limit and once you reach that limit, you’ll pay for subsequent vision care on your own. Vision coverage typically includes a deductible and copays.[15]
Individual vision policies vary depending on the company and benefits you select. However, a typical vision insurance plan may cover:
- One regular vision exam per person per year.
- Vision hardware such as frames, lenses, or contacts. Most plans set a limit for how much they’ll pay on each item — per year or every other year.
- Discounts on supplies such as contact lens solution or services such as LASIK surgery.[16]
Vision insurance policies typically don’t cover:
- Serious eye conditions: such as cataracts, glaucoma, or macular degeneration. But, they are usually covered under an ACA major medical plan.
- Eye surgeries like LASIK, though your plan may offer a discount. Your major medical insurance may cover vision-related surgeries if they are ordered by a doctor for medical reasons, it may be covered under your major medical plan.
- Special lens coatings such as polarization or scratch resistance.[17]
Vision Discount Programs
By paying a monthly or yearly fee, you gain access to discounted rates for services offered by participating providers.
When you obtain vision services, the service provider applies the discount you’re eligible for based on your discount program. Unlike insurance, you pay the service provider directly rather than submitting a claim through an insurance company. And there is no cost sharing with discount programs – no deductibles, copays or coinsurance.
Different discount programs offer different perks and “extras” but they typically include:
- Discounts on eyeglasses (frames and lenses), contact lenses, Lasik and other corrective surgery
- Nationwide provider networks so you’re not limited to your state or zip code
- Annual eye exams
- No limits on the number of times you can obtain discounted services in a coverage year[18]
Don’t Forget About Supplemental Dental!
Remember, dental coverage is much the same as vision when it comes to Obamacare: pediatric dental is considered an essential health benefit for children (though you don’t have to enroll your child in ACA dental coverage). Dental benefits are not essential health benefits for adults.[19]
Dental insurance for the whole family may still be a good idea and policies are usually relatively affordable.
Compare plan options and costs now.
Summary + Next Steps
Vision coverage, either insurance or a discount program, may be a good idea for you or your family, especially if you have or need glasses, contacts, or are considering LASIK. Depending on your age and income level, you may have access to some different vision options, including:
- Your employer-provided benefits
- Part of an ACA major medical plan purchased from the federal marketplace or your state exchange
- An individual supplemental dental policy from the private insurance marketplace
- A vision discount program
- A public program like Medicare, CHIP, or Medicaid
And don’t forget to consider dental insurance, especially if you have growing kids or you’re a senior who’s experiencing age-related dental issues.
Call (888) 855-6837 to speak with an insurance agent to discuss your options for supplemental vision or dental coverage.
