Vision Benefits | BENEFIT CARVE-OUTS

Carve-out vision benefits may be provided by insurance companies, Blue Cross-Blue Shield plans, plans of state optometric associations patterned after Blue Shield, closed-panel HMO-type plans established by local providers of vision services, vision care PPOs, or third-party administrators.

More than half of the persons covered under employer-provided medical expense plans have some type of vision coverage, and the majority of this coverage is provided under some type of carve-out arrangement. Despite concerns with rising benefit costs in recent years, vision care is one type of benefit that employers continue to add. Routine eye exams can result in better overall health care because certain other types of health problems—such as high blood pressure, diabetes, and kidney problems—are first discovered during the course of such exams. Proper vision correction can also result in fewer accidents and greater productivity by minimizing eyestrain and headaches.

Benefits are occasionally provided on a reasonable-and-customary basis or are subject to a flat benefit per year that may be applied to any covered expenses. Normally, however, a benefit schedule will be used that specifies the type and amounts of benefits and the frequency with which they will be provided. Table 11-4 is an example of one such schedule. If the plan is written by a provider of vision services, it is common for a discount, such as 20 percent, to be available for costs incurred with the provider that are not covered by the schedule of benefits. Under some plans, most benefits are provided on a service basis rather than being subject to a maximum benefit. However, these plans usually cover only the cost of basic frames, which the covered persons can upgrade at an additional expense.



Exclusions commonly exist for any extra charge for plastic lenses or the cost of safety lenses or prescription sunglasses. Benefits are generally provided for eye examinations by either an optometrist or an ophthalmologist, and larger benefits are sometimes provided if the latter is used. Vision care plans do not pay benefits for eye surgery or treatment of eye diseases because these are covered under the regular coverage of a medical expense plan.