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Posted by on Jun 5, 2013 in Benefits Perspective, Featured, From the Blog | 0 comments

Translating the Medically Necessary Contact Lens Benefit

Translating the Medically Necessary Contact Lens Benefit

One of the biggest sources of confusion with vision plans relates to benefits for contact lenses and medically necessary contact lenses.  If you or your employees are having trouble telling these two benefits apart, this explanation may improve your outlook.

Elective Contact LensesContact Lenses

When an individual requires vision correction, he or she often misinterprets a prescription as a medical necessity“I have poor vision, and my eye doctor wrote the prescription for contact lenses, which improves my vision.  Thus, my contact lenses are medically necessary.”  Unfortunately, this is not quite right.

In most instances, an individual can receive vision correction through eyeglasses, contact lenses, or sometimes laser surgery.  However, eyeglasses are considered the professional standard of care, providing an agreeable and cost-effective treatment.  The other two options are elective and considered cosmetic, for this particular scenario and most others.  Many vision plans include an elective contact lens benefit in lieu of eyeglasses, meaning an individual may choose to correct his/her vision with contact lenses instead of eyeglasses.

So the correct interpretation of most vision correction prescriptions would be, “I have poor vision, and my eye doctor prescribed some type of vision correction to improve my eyesight.  Instead of eyeglasses, I chose the contact lens option.”  The vision plan member still has a benefit for contact lenses; the benefit is just equal to or up to the amount for eyeglass lens materials.

Medically Necessary Contact Lenses

Medically necessary contact lenses are non-elective contact lenses prescribed when certain medical conditions hinder vision correction through regular eyeglasses.  In other words, contact lenses are a medical necessity and the generally accepted standard of treatment.

With some medical conditions, patients are unable to achieve a specified level of visual acuity or performance through regular eyeglasses. This results in the need for “medically necessary contact lenses”. Such medical conditions include:

  • Aphakia – the removal or absence of the lens of the eye(s) due to surgery, injury, or abnormality.
  • Anisometrophia – a refractive condition where the eyes have unequal focus or optical power
  • Keratoconus – an eye disease that causes structural damage to the eye’s cornea, changing from the normal, round shape to a bulging, cone shape.

Usually, the medically necessary contact lens benefit is greater than the elective contact lens benefit, and some vision plans will pay a benefit for medically necessary contact lenses even if the plan does not have elective contact lens coverage.

Regardless of your vision plan or carrier, it is in your employees’ best interest to communicate with your vision carrier and understand what is required to qualify for the medically necessary contact lens benefit.  For example, at AlwaysCare, we require a certain request form be completed and signed by the member’s doctor to qualify. It’s quick and easy to handle, and makes the benefit easy to use.

“See the difference…”

We hope you can now see the difference between elective contact lenses and medically necessary contact lenses.  The benefits outlined here are just a part of a typical vision plan, however. Just like any benefits you offer your workforce, a vision plan works best when employee communication is ongoing and consistent.

What part of your vision plan do you have the most trouble communicating with your employees? What have you done that’s worked really well? We would love to hear about it in the comments…

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