Understanding Provider Networks
and Vision Insurance Plans

By Madeleine Vessel

Vision insurance plans offer similar benefits, but may vary in important ways such as in how many providers are included in the approved network that offers eye exams, eyewear, and other services. Also, vision plans may differ depending on whether services are discounted or offered as part of a benefits package.

Understanding Eye Care Provider Networks

Eye care provider networks contract with vision insurance organizations to provide eye care services at discounted rates for participants in a vision insurance or benefits plan.

• If vision insurance is linked to an HMO (Health Maintenance Organization), participants usually are required to obtain services only from network providers.
• If vision insurance is joined to a PPO (Preferred Provider Organization), participants usually are allowed to access out-of-network providers — but at a greater cost.
• If vision insurance is added on to an indemnity insurance plan, participants can use any provider they wish.
• If the vision plan is purchased directly from a vision insurance company, it likely will function like a PPO plan.

[Read more about indemnity insurance plans, HMOs, and PPOs]

To evaluate an eye care provider network for yourself or for your employees, consider the following:

Are there enough and the right selection of network providers within close proximity of either your home or your workplace to serve eye care needs?

Ask yourself:

• How long would the typical wait be for an appointment with a network provider?
• Would an unacceptable amount of travel be required to visit a network provider?
• Are favored providers on the list? Does it matter?
• Are the network providers on the list trustworthy?

When you have answered this list of questions, you should have enough information to decide whether a provider network meets your needs.

Understanding Vision Benefits Packages

Vision benefits packages provide participants with specific eye care services in exchange for an annual premium or membership fee.

Basic coverage includes a comprehensive eye examination and a pair of eyeglasses or set of contact lenses. Allowances are sometimes given for designer frames, specialty lenses, and LASIK or PRK refractive surgery.

A participant sometimes must pay a deductible, which is a minimum dollar amount, before plan services go into effect. Often, a participant must pay a co-pay, which is a fixed dollar amount, each time they access a service from a network provider. Usually, limits are put on the numbers of times a participant may access a service.

Most vision benefits packages also give allowances for services accessed through out-of-network providers. Typically, a participant using an out-of-network provider pays the provider in full at the time of service, then requests reimbursement of an allowed portion of the costs from their vision insurance company.

The premium or membership fee amount depends on the level of coverage the plan provides — full service, eye exam only, or materials only. The number of family members covered and the amount of co-pay also are factors in determining the amount of the premium.

With a group benefits package, the premium or membership fee typically costs about $20 a month per employee. An employer can choose to pay a portion of each employee's premium or not.

A vision plan you buy as an individual may have a higher premium because you do not benefit from group coverage offered through a company or organization.

Understanding Vision Discount Plans

Vision discount plans, in exchange for an annual premium or membership fee, permit participants to access a network of eye care providers who have promised to provide designated eye care services at fixed discount prices. As with vision benefits packages (see above), these usually include a comprehensive eye examination, a pair of eyeglasses, and/or set of contact lenses. Some plans may include discounts for LASIK or PRK refractive surgery.

Often, a participant pays the vision insurance company the discounted price for the services desired in advance of the service. When the vision insurance company receives payment in full, it issues the participant either a set of coupons, a debit card, or an I.D. number (which often must be verified by the provider) guaranteeing the provider that the discounted prices will be paid by the vision insurance company.

Another scenario is that the participant shows the vision plan I.D. and pays the discounted prices directly to the provider at the time of service. Generally, participants can use discounted services whenever and as often as they wish.

Most vision discount plans also allow out-of-network services. When a participant uses an out-of-network provider, they pay in full at the time of service, then request reimbursement of an allowed portion of the total cost from their vision insurance company.

The amount of premium or membership fee depends on the level of coverage the plan provides, the number of family members covered, and the amount each service is discounted below regular retail prices.

The premium or membership fee for a group vision discount plan usually costs about $20 a month. An employer can choose to pay a portion of each employee's premium, or not.

Without the advantage of group coverage offered through a company or organization, a vision discount plan you buy as an individual may have a higher premium.

[Read more about vision insurance, how to use your vision insurance benefits, and how to shop for a vision benefits plan.]

[Page updated October 2006]