Eye Health & Plan Design

Eye Care Benefits Toolkit

Plan Design & Networks: Eye Health & Plan Design

Eye Health & Plan Design

The number of people who have some type of vision benefits has been increasing recently. Still, half of the U.S. adult population has no coverage for routine and preventive eye health and vision care services (e.g. comprehensive eye exams) or corrective eyewear such as glasses or contact lenses. Also worth noting, studies have found that insurance is an independent predictor of vision health. Those without insurance have a higher incidence of vision loss and are diagnosed at a later age with degenerative eye diseases like glaucoma and cataracts than those with insurance.

Benefit Design Snapshot

A consumer survey found that 93% of respondents identified vision benefits as somewhat or very important, just slightly less than that for general medical insurance (94%). And research has shown just having coverage increases the likelihood of having an eye exam. Approximately 63% of adults without vision benefits reported they would get an eye exam if they had a vision insurance plan, and 50% reported they would buy and use eyeglasses if needed and covered.

A streamlined and integrated strategy for eye health and vision benefits can be a key aspect of an employer’s benefits package that increases employee satisfaction and loyalty. In addition, this type of strategy can help to:

 

  • Reduce the overall health risk score of a covered population
  • Educate employees and covered dependents about benefit plan coverage, including the importance of regular comprehensive eye exams to protect eye health, and for the detection and early management of chronic conditions
  • Emphasize the company’s commitment to preventive care and health improvement

 

Vision benefits can be offered by employers in a variety of ways:

Stand Alone Vision Benefit Plan

Old-fashioned, prepaid discount plans  for eye exams and eyewear is often provided to employees and covered dependents as a separate, voluntary benefit. Most employers offer vision benefit plan coverage as a 100% employee-paid benefit. Typical plans cover a yearly eye exam through a network of providers, with or without a copay. Coverage for frames, lenses and vision-correcting contacts are available with a discount, flat-dollar copay or dollar limit by type of product or service offered. Vision benefit plans may be fully-insured by the vision carrier or self-insured by the employer. 

Medical Plan

Eye health coverage, integrated in the medical or health plan carrier or third-party administrator (TPA), is commonly self-insured by the employer. Self-insuring can provide flexibility to the employer in determining what benefits and level of coverage they wish to extend to their employees and covered dependents. Vision benefits for adults under the medical benefit is not required under the Affordable Care Act. Self-insured employers may choose to include a comprehensive eye exam for employees and their dependents 19 years old and over. Medical plans that include vision coverage are most frequently a shared cost between the employer and the employee, as that is typically how medical plans are funded.

Value-Based Benefit Design

This type of benefit promotes integrated eye health coverage focused on preventive comprehensive eye exams, paired with coverage and/or discount programs to support prescription eyewear. This is an effective strategy for providing an enhanced benefit while saving money for both the covered population and the company. 

HSA/FSA Contributions

Employers may choose to contribute to a Health Savings Account (HSA) or Flexible Spending Account (FSA) for employees to use at their discretion for eye exams and prescription lenses for themselves and covered dependents. According to a 2018 American Eye-Q® Survey, nearly half of Americans with an HSA or FSA have used the funds to pay for a comprehensive eye exam. Of those who were unaware they could use their HSA/FSA in this way, 90% agree they would use the funds for comprehensive eye exams. This strategy can encourage employees to use their benefits by covering routine comprehensive care and allowing individual choice on treatment purchases.

 

A Note About the Affordable Care Act

Coverage for pediatric vision care is required as part of pediatric care, one of the 10 essential health benefits many employers must provide to comply with the ACA.  For children under the age of 19, vision benefits are included in all new individual and small group market plans (with effective dates of January 2014 or later), on and off-exchange. This means children have coverage for eye exams and glasses or contact lenses to correct vision problems.