Glossary of Vision Insurance Terms
o understand vision insurance benefits, it helps to know the terminology used to describe different plans. Here is a list of terms you will likely encounter when discussing vision insurance and eye care benefits:
calendar year The 12-month period beginning January 1 and ending December 31.
capitation A set dollar limit that you or your employer pay to a health maintenance organization (HMO), regardless of how much you use (or don't use) the services offered by its health care providers.
carrier The insurance company or HMO offering a health plan.
coinsurance A vision insurance plan member's share of the costs of a health care service after the deductible has been met. Coinsurance usually is stated as a percentage of the amount the insurance company allows to be charged for a given service. For example, if your insurance company pays 80 percent of the allowed fee for a service under your plan, your coinsurance is 20 percent.
copay A copayment or "copay" is a fixed payment that an insurance plan member pays at the time a medical service is provided by a network care provider. A copay also may be required when you get a prescription filled. The copay is separate from the coinsurance payment (typically invoiced after the service is provided), which also may be required, depending on the terms of the insurance policy.
coverage The eye care services listed as benefits in a vision insurance plan.
deductible The amount you must pay for health care or vision care services before your health plan or vision plan pays its portion of the costs. Typically insurance plans have yearly deductible amounts.
defined contribution plan A health plan in which an employer places a certain amount of money each year into an employee account that can be used to pay medical expenses.
denial (of claim) The refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for health care or vision care services.
dependents The spouse and/or children (whether natural, adopted or stepchildren) of an insured person.
exclusions Health care or eye care services that are not covered by your insurance plan.
flexible spending account (FSA) Sometimes called a flex plan, an FSA allows an employee to use pre-tax dollars to purchase certain health benefits, such as eye care and vision benefits, which may not be covered by your insurance plan.
generic drug A medication that is essentially identical to a brand-name drug. Generic drugs can be marketed by competitive companies once the patent for the brand-name drug has expired. Generic drugs are cheaper, and many health plans encourage clients to choose them over the original brand-name medication for this reason.
group vision insurance Vision insurance purchased by an organization such as a business, association or union that covers all individuals in the group.
HIPAA The federal law (called The Health Insurance Portability and Accountability Act of 1996) that, among other things, safeguards the privacy of your medical record and limits the sharing of personally identifiable information about patients. HIPAA also allows you to qualify immediately for comparable health insurance coverage if you change your employment or relationships. When you visit your eye doctor for vision care services, you will receive written information about HIPAA and be asked to sign a form verifying that you have received it.
HMO (health maintenance organization) A group of health care providers that offer pre-paid (or "capitated") insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly capitation fees remain the same, regardless of types or levels of services provided.
HSA (health savings account) A savings account you can set up that enables you to pay for your current and future health care and eye care services with pre-tax income. To open an HSA, you must have a high-deductible health insurance policy.
indemnity insurance plan An insurance plan in which you pay for services (such as eye care) out-of-pocket at the time service is provided, then submit a claim for reimbursement for some or all of the cost to the insurance company. Most indemnity plans allow you to choose any eye doctor you wish — you are not limited to doctors in a PPO or HMO. A deductible and co-payment often is required. (Also called a fee-for-service insurance plan.)
individual vision insurance Eye care coverage sold to an individual as opposed to a group. The membership fee for an individual plan usually is higher than membership fees for participants in a group plan.
IPA An independent practice association of health care and/or eye care providers. IPAs are similar to HMOs, except you receive care in a physician's or optometrist's own office, rather than in an HMO facility.
managed vision care A delivery system for vision care that attempts to manage the quality and cost of eye care services. Managed vision care typically is provided via an HMO or a preferred provider organization (PPO) that includes independent eye doctors.
membership fee The annual fee paid to keep a vision plan in effect.
network A group of doctors, hospitals and other health care providers (including eye care practitioners
) that have agreed to provide services to health plan members for less than their usual fees.
out-of-network In vision care, optometrists and ophthalmologists that have not contracted with a vision insurance organization to provide eye care services at discounted rates.
outpatient services Health care services (including cataract surgery and LASIK surgery) that do not require an overnight stay in a hospital or other medical facility. Many insurance companies will not cover the costs associated with certain tests or procedures unless they are performed on an outpatient basis.
PPO (preferred provider organization) A network of health care providers organized by an insurance company to provide health care services to policyholders at discounted rates. Policyholders may choose to obtain health care from out-of-network providers, but at higher costs.
premium The annual fee paid to keep a health care or vision care plan in effect.
primary care provider In eye care, an optometrist or ophthalmologist who is responsible for monitoring an individual's overall eye care needs. The primary eye care provider performs comprehensive eye exams and refers individuals to more specialized physicians for additional care when needed.
provider A health care professional (including optometrists and ophthalmologists) that provides services to patients.
Page updated April 2018