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How is vision care covered under the Affordable Care Act?

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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 small group and individual health insurance 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 your employer offers health insurance, there’s a good chance that vision coverage is included in your employee benefits 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.

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. In most states, stand-alone vision plans are not offered through the exchanges, and even if they are, you can’t use your premium subsidy to offset their cost. (used in 36 states as of the 2021 plan year) does not offer any stand-alone vision plans. But several of the fully state-run exchanges have established partnership arrangements with a stand-alone vision coverage company (VSP, in most cases, although California’s exchange also works with EyeMed; details here: California, Colorado, DC, Idaho, and Nevada). In these states, visitors to the exchange are directed to a link where they can purchase stand-alone vision coverage directly from the vision coverage provider.

Optometry versus ophthalmology

When we talk about vision coverage, we’re generally referring to optometry care. This involves the process of vision testing and correction, and is generally not covered under health insurance plans for adults.

However, ophthalmology services to treat eye injuries, illnesses (such as cataracts), or infections would generally be covered by health insurance policies, subject to the same cost-sharing as other medical conditions. Note that although LASIK surgery is done by ophthalmologists, it is almost never covered by self-purchased health insurance; LASIK falls under the category of vision correction, rather than treatment for an injury or illness that’s affecting the eye.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Maria Frocke
Maria Frocke
6 months ago

So if I have an eye infection or injury to my eye, many medical insurance policies do not cover an ophthalmologist. That is outrageous!!!

Louise Norris
6 months ago
Reply to  Maria Frocke

If it’s an eye injury or infection, treatment by an ophthalmologist should be covered by your health insurance (although depending on the deductible and other cost-sharing rules for the plan, you may pay a significant portion of the charges out-of-pocket). The article above is referring to optometry care, which is generally not covered for adults on standard health plans.

Carmen Ruiz
Carmen Ruiz
3 months ago

Does “Employer Health Insurance” includes Employer Retiree benefits?. As a County former employee (from 25 years ago) I qualify for their Health Ins. 400 premium Monthly. I rather enroll in Covered California but not sure if I qualified.
60 years old now and self employed but was getting unemployment benefits in 2021.

Louise Norris
3 months ago
Reply to  Carmen Ruiz

Yes, you can qualify for a premium tax credit through Covered California, as long as you decline the retiree health coverage. Retiree health coverage isn’t viewed the same as active employee health coverage when it comes to eligibility for premium tax credits in the marketplace. This article has more information:

If you were getting unemployment compensation at any point in 2021, and assuming you weren’t/aren’t eligible for an active employee plan (your own or your spouse’s), you can qualify for the American Rescue Plan’s enhanced subsidies based on unemployment compensation:

Assuming you’ve been enrolled in a plan through Covered California this year, you can claim the full amount of your premium tax credit when you file your 2022 tax return.

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