Understanding Provider Networks
and Vision Insurance Plans

By Madeleine Vessel, with updates by Gary Heiting, OD

Vision insurance plans may offer similar benefits but vary in important ways, such as in how many eye doctors are members of the plan's provider network.

Optometrists and ophthalmologists in the provider network offer eye exams, eyewear and other services covered by the vision insurance plan at no charge or at discounted fees compared with doctors outside the network.

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. This arrangement can take several forms:

• 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]

Evaluating an Eye Care Provider Network

When evaluating an eye care provider network for yourself or for your employees, consider the following:

• Is there a good selection of network providers within close proximity of either your home or your workplace to serve eye care needs?
• How long must you wait for an appointment with a network provider?
• How much travel is required to visit a network provider?
• Is your current eye doctor a member of the network?
• Are network providers highly recommended in their communities?

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 sometimes are 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, participants must pay a co-pay, which is a fixed dollar amount, each time they access a service from a network provider. Usually, limits are set on the number 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.

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 in advance for a membership card or an I.D. number (which often must be verified by the provider) that authorizes the participant to receive discounted prices from the eye care provider.

Generally, vision discount plan members can obtain discounted services from the plan's network of providers whenever and as often as they wish during the coverage period.

Most vision discount plans also allow out-of-network services. When participants use 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 the 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, the amount each service is discounted below regular retail prices and whether the plan is a group plan or an individual plan.

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 how to use your vision insurance benefits and how to shop for a vision benefits plan.]

[Page updated December 2009]