Insurance

Insurance introduction

The following is a brief overview of various plans common to the White Mountain area.  As a Barnet Dulaney Perkins facility, we accept medical plans such as Aetna, BlueCross, Cigna, United as well as several others. We also work with most major Vision Plans. Although Barnet Dulaney Perkins Eye Center has several offices throughout Arizona, not all providers are contracted at all locations with all insurance plans. If this location is not contracted, we will be happy to recommend one of our locations and/or providers that can utilize your insurance.

We provide medical eye care AND vision coverage  for several large employers such as State of Arizona, Navajo county, Apache county, Summit Hospital, as well as the White Mountain Apache Tribe and others.

As always we will help you maximize your benefits when ever possible. But cannot guarantee benefits, even if we are a direct contract provider. It is best to determine coverage prior to your visit.

The information contained in the following pages is subject to change. If you do not see your plan, just email us for current information.

Understanding Your Vision Plan

Let’s face it, insurance can be confusing. This is particularly true when an individual has both medical and vision coverage. Understanding your insurance PRIOR to any service can help you avoid confusion and frustration.

Unfortunately VISION INSURANCE is one of the most misunderstood benefits of all health-related coverage. And it doesn’t help that most insurance company “customer service” departments tend to exaggerate and overstate benefits (and minimize or even ignore specific limits and restrictions) often creating an adversarial relationship between patient and the doctor’s office.  Some insurance companies do a better job of educating their clients than others. Hopefully the following will help you better understand how vision coverage works. As always, feel to ask questions regarding your specific plan coverage.

Medical vs. Vision

 Medical insurance is NOT vision and Vision insurance is NOT medical. Most vision plans do not cover ANY medical testing, diagnosis, consultation or treatment.   Vision insurance covers only vision (ie, glasses or contact lens testing, etc). If there are any medical concerns, it falls under medical coverage.

MEDICAL is always a priority, and as such will be treated first or concurrently with a vision problem. Sometimes a medical condition has to be treated and corrected before vision can be accurately evaluated.

If you have a medical issue and you only have vision insurance (or unmet deductible on your medical coverage), ask about using your vision benefit and paying the medical portion out-of-pocket. This usually cost much less and is more convenient than a separate medical visit.

If you are using your medical insurance for a medical issue, it may also be possible to add a vision evaluation for a small fee. Sometimes both vision and medical coverage can be combined (such as BCBS Arizona).

 

All vision plans are NOT created equal

Since 1995 Dr. Lee has evaluated over 60 vision plans assisting individuals and employers in their search for best coverage. Many are not worth the paper they were written on and have since come and gone. Some are nothing more than sales gimmicks to get customers into national chain-stores.

Even legitimate vision plans can sometimes have surprising limitations as they attempt compete with low-end plans. But the biggest problem is often misleading or “unclear” marketing on the part of the vision plan itself.

For example a plan may advertise “free eyeglasses”, but not tell the patient they only send the provider $15 for a frame.  Lenses may be listed as “covered in full” but nothing is mentioned as to what type of lens is covered. Is it CR-39, glass, high-index, single vision, bifocal, or progressive? And if progressive… what brand(s) are allowed? What about edge polish, coatings, warranties, and upgrades? Is there enough payment to cover consultations, dispensing, and ongoing comfort adjustments or minor repairs?

Some plans even restrict what lab can be used, or limit the quality. And if the patient’s choice is not from an “approved list”, the insurance company will pay zero.

What about the exam itself? Most companies love to call it a “comprehensive” eye exam but never mention it is for glasses only and doesn’t cover medical. And if contact lenses are wanted, the contact lens testing or update comes from the contact lens benefit (hopefully the plan has a contact lens benefit). If the contact lens benefit is high, it is never a problem but if the benefit is low, the patient is in for a surprise. Instead of having “$100 for contacts”, after the testing or update exam, there may only be $50 or $60 left for the actual contact lens. Worse yet are the plans that say $100 “allowance” but really only send the provider $25 or $30 for contact lens services and/or materials.

For most vision plans, all the pricing is based on usual and customary fees. In most cases, YOU CAN NOT TAKE AN IN-OFFICE DISCOUNT AND COMBINE IT WITH INSURANCE (you may be able to do this if YOU send the bill to the insurance yourself instead of having the doctor bill the insurance).

The easiest, and most simple plans, state a dollar benefit and the patient pays the difference.  One such company is Vision Care Direct (“VCD”). These plans often have high satisfaction ratings because the patient knows exactly what they get; benefits are clearly understood and have no unreasonable or hidden restrictions or limitations.

Glasses or contacts

Most vision plans restrict materials to either glasses OR contact lenses, not both!  Most plans pay more for contact lenses than glasses. If you wear both, it is almost always best to use the benefits for contact lenses.

There are some exceptions to this, so ask us which choice is best for you.  The contact lens evaluation (or yearly contact lens update) is subtracted from the total contact lens benefit, thus reducing the balance available for materials. Remember, the “exam” benefit only pays for eyeglass testing, not contact lens services. Contact lens services as well as materials are covered by the contact lens portion of the insurance.

The number of contact lenses a you receive will be determined by the plan’s total contact lens benefit minus the balance remaining after the evaluation, the type of contact lenses, and specific prescription parameters.

Complicated eye conditions my further increase the cost of the evaluation so keep your eyes healthy by using the best lenses available and following ALL of the doctors instructions.

Out-of-Pocket costs

Unfortunately, many vision insurance companies sell multiple and varied plans, so it is not always easy to determine exact out-of-pocket costs for materials until you choose your eyewear.   As a rule, the more costly the insurance premium, the less out-of-pocket cost you have when you buy eyewear. But this is NOT always the case!  There are situations (and other limitations within specific plans) that can make it not worth the extra monthly premium. Our office can help you determine if it’s worth paying the extra cost for the higher-premium policy.

Bottom line, what do you owe?  Some plans do better than others in keeping TOTAL costs down (premium plus out- of -pocket costs). Some may charge a higher monthly premium but lower your cost for materials when eyewear is purchased. Other plans may have a slightly lower monthly premium but also have slightly higher material out-of-pocket costs later.

Surprisingly, sometimes the plan with the lower monthly cost but higher out-of-pocket may actually be the best insurance value because fewer restrictions may apply when you order materials

Very cheap plans are almost never worth the premiums paid. These plans are so restrictive that benefits are highly questionable. They also tend to force the provider to use low-end “junk” materials which is never a good thing. These plans are also the most misleading and cause the most confusion and frustration for both doctor and patient.

Many of these “bogus” plans claim savings of 30-70% for eyewear or specify unreasonable low fees, yet actually send NOTHING to cover costs.  The only way any provider can honor this kind of plan, is to have outrageously high mark-ups and/or use very low-end materials.  Hint: if your plan has far more department store or “box” store optical chains than private eye doctors, chances are it is one of these questionable plans.

Regardless of your vision insurance, most plans simple do not cover 100% of expenses, and thus you should expect some out-of-pocket costs. At our office, as with most doctors, the patient’s portion must be paid before materials can be ordered. And all co-pays are due at time services are rendered.

Our office is here to assist you in maximizing your benefits. We will always try to give you several basic and upgrade options when ever you purchase from us.

And if you don’t have vision insurance,  we have several cash- saving programs as well.

 

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