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What is the difference between routine eye examinations and a visit for medical care?

Your visit for routine eye care allows your eye doctor to evaluate your visual needs. The doctor can determine if there is a need to prescribe or change your prescription for vision correction. It also allows him/her to evaluate your eye health, to rule out the most common eye diseases and to determine if there is a need for further evaluation and procedures.

What is vision Insurance and how does it differ from medical insurance?

Vision insurance is usually a separate insurance covered by your employer or insurance company that covers routine eye care and may or may not include payments towards eyeglasses or contact lenses. It cannot be used to treat medical problems. Medical eye care involves visits and procedures your doctor performs to diagnose and to treat eye disease such as glaucoma, dry eye, conjunctivitis and cataracts. It may or may not include determination of your eyeglass prescription.

Does my medical insurance cover routine eye care?

Typically, your major medical insurance or managed care plan pays for procedures needed to diagnose and treat eye disease. While the examination may provide you with a new eyeglass prescription, medical insurance rarely pays for routine care and refractions.

Does insurance cover refractions?

Many of the examinations and tests performed at SUNY College of Optometry evaluate your eyes for possible disease. Once a disease is found, examinations and tests allow us to manage your eyes appropriately. There is however, one test called a refraction that is typically not covered by insurance that needs to be performed at least once a year. It is not an optional test, but essential to fully evaluate your eyes appropriately. Federal guidelines state that the office visit and the refraction are to be reported as two separate charges when submitting your services to Medicare and other insurances. Most medical insurance carriers do not cover charges for the refraction and there is a separate charge for this service. The payment for the refraction must be made at the time of service along with your copay and any deductible amounts for the covered charges for your visit.

How often should I make an appointment according to the American Optometric Association?

Recommended Examination Frequency for Pediatric Patients

 Asymptomatic/Risk FreeAt Risk
Birth to 24 MonthsAt 6 months of ageBy 6 months of age or as recommended
2 to 5 yearsAt 3 years of ageAt 3 years of age or as recommended
6 to 18 yearsBefore first grade and every two years thereafterAnnually or as recommended

Children considered to be at risk for the development of eye and vision problems may need additional testing or more frequent re-evaluation. Factors placing an infant, toddler, or child at significant risk for visual impairment include:

  • Prematurity, low birth weight, oxygen at birth, grade III or IV intraventricular hemorrhage
  • Family history of retinoblastoma, congenital cataracts, or metabolic or genetic disease
  • Infection of mother during pregnancy (e.g., rubella, toxoplasmosis, venereal disease, herpes, cytomegalovirus, or AIDS)
  • Difficult or assisted labor, which may be associated with fetal distress or low Apgar scores
  • High refractive error
  • Strabismus
  • Anisometropia
  • Known or suspected central nervous system dysfunction evidenced by developmental delay, cerebral palsy, dysmorphic features, seizures, or hydrocephalus

Recommended Examination Frequency for Adult Patients

 Asymptomatic/Risk FreeAt Risk
18 to 60 yearsEvery two yearsEvery one to two years or as recommended
61 and olderAnnuallyAnnually or as recommended

Patients at risk include those:

  • with diabetes, hypertension, or a family history of ocular disease (e.g., glaucoma, macular degeneration)
  • working in occupations that are highly demanding visually or eye hazardous
  • taking prescription or nonprescription drugs with ocular side effects
  • wearing contact lenses
  • who have had eye surgery
  • with other health concerns or conditions.

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