Medical Insurance & Vision Therapy

Will My Insurance Cover Vision Therapy? The answer to this question depends entirely on the quality of your insurance policy. The better companies, which genuinely try to provide the service they promise, routinely cover Vision Therapy. Many of these companies have faithfully covered vision therapy for decades. In fact, one of the best ways to determine the quality of your insurance company is to determine if they do cover vision therapy. If they do not, you will probably find your company's service lacking in a number of other ways as well, and you may want to begin looking for—or have your company begin looking for—a more substantial policy.

Medical vs. Vision Insurance

Vision therapy is typically not covered by routine optical benefit plans. Such plans cover eye examinations and glasses. Glasses solve 'refractive' eye problems but not medical eye problems such as learning disabilities. Instead, vision therapy falls under the area of Major Medical. Insurance policies vary widely. Some policies have page after page of 'excluded services.' Other policies have few exclusions and really provide the 'comprehensive care' that they advertise.

The general rule is, 'You get what you pay for.' But even here, there can be disappointments. Some well-known plans, unfortunately, do not really provide the benefits they lead you to believe. When such policies are carefully investigated, they are found to fight paying for many different services which you would expect them to cover. Vision therapy may or may not be one of these services.

How May a Company Try to Justify Not Paying for Vision Therapy?

With a good company, it is not uncommon to have your reimbursement in the mail within two to four weeks. Lesser companies may delay your payments for weeks or even months. You may be subjected to 'medical reviews' performed by doctors who turn out to be salaried by the company itself or, worse, 'independent consultants' who, when investigated, are found to have no optometric training or certification of any kind in vision therapy.

What Percentage of My Therapy Program Will Be Covered?

Most policies cover 80 percent. However, some policies actually cover a lesser percentage by limiting the number of visits allowed for vision therapy. An investigation of this matter disclosed that for the same vision problem, the number of visits allowed by insurance companies varied between 10 visits and 75 visits.

Do Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs) Cover Vision Therapy?

Both HMOs and PPOs were designed to cut costs by rewarding doctors for providing fewer services. The PPO, for instance, contracts with a company to provide all 'needed care' for that company for a lump sum of money. The less care that is provided, the more money is left over to be divided among the PPO and the participating doctors. As a result, PPOs tend to provide the bare minimum of services. Since specialty services generally cost more to provide, PPOs make such services much more difficult to obtain than traditional major medical policies. As a result, Vision Therapy is seldom covered by HMOs and PPOs. Because the doctors involved in such plans are financially rewarded for limiting care, they can be very convincing in the arguments they use to justify excluding coverage for any number of services—vision therapy being just one of many 'excluded services.'

What Do I Do If Insurance Is a Problem?

Ask your doctor for help if your insurance company begins to cause problems.

Companies do not reject claims. Individuals in companies reject claims. Always get the name of the individual who is responsible for withholding your payment. This information may become necessary, especially if legal action is required.

If problems continue, do not hesitate to alert your employer to any difficulties you are having so a more service-oriented insurance company can be found in the future.

The most important thing to remember is NOT to delay treatment while waiting for your insurance company to act. If your insurance company is good, you will be reimbursed. If your insurance company is limited, you may not be covered. In either case, you do NOT want the insurance company to decide the fate of your family. Needed care is needed care, and problems can grow worse if left untreated, resulting not only in more upset for your family but more expense as well.

This information was originally made available as a public service by the College of Optometrists in Vision Development. Modifications were made for the purposes of our clinic.