Vision Exam (Well Vision Screening)

A vision exam focuses on assessing your overall visual acuity if you do not have any known eye diseases or systemic conditions that impact your eyes. In this type of exam, a doctor—often an optometrist—evaluates your need for glasses or contact lenses, checks for basic refractive errors, and screens for any glaring abnormalities. However, if something abnormal is found that requires further medical testing or treatment, the exam may be converted into a medical exam. This is because ophthalmologists and optometrists have a responsibility to address significant findings rather than overlook them simply to fit a “vision” coverage category.

Medical Exam

A medical eye exam is performed when you have a pre-existing or newly discovered eye condition, symptoms that suggest an underlying problem, or certain systemic health issues that can affect the eyes (such as diabetes). Conditions like cataracts, glaucoma, or macular degeneration typically fall under medical insurance coverage. Likewise, yearly diabetic eye exams are billed to medical insurance, not vision coverage. A medical eye exam often involves a more thorough clinical assessment, potentially including diagnostic tests, imaging, or the prescription of medications.

• Routine Eye Exams and Preventive Care – Vision plans usually cover routine checkups that evaluate how well you see and whether you need corrective lenses.
• Eyewear – Many vision plans help cover glasses or contact lenses, including part or all of the cost of frames, lenses, or contact lens fittings.
• Limitations – Vision insurance generally does not cover medical or surgical treatments. Procedures like cataract removal, laser treatments for retinal conditions, or complex diagnostic testing typically require medical insurance.

• Eye-Related Medical Conditions – Medical insurance covers exams, treatments, and follow-ups related to eye diseases or injuries, such as glaucoma, diabetic retinopathy, and infections.
• Surgical Procedures – Surgeries like cataract removal or laser procedures for retinal issues fall under medical insurance. Some plans also include preventive eye exams, though it varies, so you may want to confirm this with your insurance provider.
• Referrals and Requirements – Certain insurance plans require a referral from your primary care physician before you can see an ophthalmologist. Checking your policy details or calling your insurance provider can help clarify these steps.

It’s not uncommon to schedule what you believe is a simple “routine vision” exam, only for the doctor or technician to identify signs of a condition that requires medical evaluation—perhaps high intraocular pressure or early signs of cataracts. In these cases, the exam transitions to a medical one because the focus shifts to diagnosing and potentially treating a disease rather than just prescribing glasses or contacts. This means your medical insurance, rather than your vision plan, will be billed. It’s also important to know that if your plan doesn’t cover the refraction portion (the test that determines your glasses prescription), you may have an additional out-of-pocket cost.

As a general guideline:

• Optometrists often handle routine vision checks and corrective prescriptions, typically billed through vision insurance if there’s no underlying disease.
• Ophthalmologists diagnose and treat medical eye conditions, usually billing medical insurance.

However, these roles may overlap, as optometrists also detect and manage various eye conditions and may switch an appointment to a medical exam if a problem arises.

A refraction test determines your best-corrected vision and is often needed in both vision and medical exams. Some insurance plans do not cover refractions. In such cases, you may be responsible for an additional fee at the time of service. Even if glasses or contacts aren’t ultimately prescribed, a refraction may be necessary to fully assess your visual function or to track changes related to a medical condition.

Eye care insurance can be complex, especially when certain policies only pay for “well vision” visits and others require a medical reason for coverage. Ultimately, it’s your responsibility to understand your specific plan’s guidelines, but Illinois Eye Center is here to help. If you’re unsure about which coverage applies—or if you’re wondering whether your upcoming appointment will be considered routine or medical—please call us at 309-243-2400.

Our experienced staff can walk you through the details of your plan and make sure you’re prepared ahead of your visit. Whether you need a well vision exam or a more comprehensive medical assessment, we’ll guide you toward the appropriate level of care and ensure you receive the right treatment for your eyes.