Q: How is vision care covered under the Affordable Care Act?
A: The Affordable Care Act requires coverage for pediatric vision care as one of the essential health benefits. So for children under the age of 19, vision coverage is included in all new individual market plans (with effective dates of January 2014 or later), on and off-exchange. This means kids have coverage for eye exams, vision screening, and glasses or contact lenses to correct vision problems.
Vision screening for children falls under the category of preventive care, which means it’s covered at no charge until kids turn 19 (as long as you have an ACA-compliant plan). But vision screening is not the same thing as an eye exam. Vision screening can be performed by a pediatrician or family physician to identify or detect vision difficulties. The screening may not diagnose the child’s condition, but it can indicate whether the screening should be followed up with a comprehensive exam.
Although pediatric vision care beyond vision screening is covered under the ACA, everything other than vision screening can have copays, or be counted towards the deductible and/or covered with coinsurance. Some carriers do offer free eye exams and glasses for kids though — it depends on the carrier, so read the fine print on the plans you’re considering.
What about adults?
Vision care coverage is not mandated for adults by the ACA. Health plans can opt to include adult vision coverage in their benefit design, but they are not required to do so.
If the health plan you’re considering — on or off-exchange — doesn’t include adult vision coverage, you may want to purchase a stand-alone adult vision plan. Stand-alone vision plans are not offered through the exchanges, and you can’t use your premium subsidy to offset their cost.
If your employer offers health insurance, there’s a good chance that vision coverage is included in your employee benefit package. If it’s not, you can purchase a stand-alone vision plan. Depending on how much vision care you use, it may or may not make financial sense to do so.