Affordable Care Act Vision Coverage

Vision insurance generally isn’t covered under the Affordable Care Act (ObamaCare).  However, pediatric eye care is a required benefit included on all plans that qualify as minimum essential coverage under the ACA.

Even though adult vision coverage isn’t a required benefit of ObamaCare, “vision health” is still an important aspect of wellness.  On this page we will discuss what vision insurance is, how you can get an eye care plan, and how the new healthcare law affects vision coverage.

Vision coverage is a health benefit that at least partially covers vision care, like eye exams and glasses. All kids under 19 in individual, family, and small group markets must be offered vision benefits.
If vision benefits are part of the plan, you can use cost assistance. If vision benefits are part of a stand-alone plan, you cannot use cost assistance. This is true for kids and adults.

Vision Coverage: How it Works with the ACA

Here is a quick summary of what you need to know vision insurance under the Affordable Care Act:

  • Vision coverage is a required for children as an Essential Health Benefit (EHB).  All Qualified Health Plans must cover basic eye care services for children 18 or younger.
  • The pediatric vision services covered as an EHB include annual examinations, glasses (both lenses and frames), and contact lenses instead of glasses.
  • Marketplace health plans do not have to offer vision care to adults.
  • Adults can purchase vision coverage either as a part of their marketplace insurance or as a stand-alone vision plan.
  • Stand-alone vision plans are not available directly from the federal or state marketplaces and must be bought from a private health insurance provider.
  • You can only apply tax credits to vision coverage if that coverage is part of a Marketplace plan.
  • You cannot apply tax credits to stand-alone vision plans.
  • Most of the ACA’s benefits, rights, and protections (like new cost sharing requirements)  don’t apply to dental and vision coverage.
  • Your marketplace health insurance must cover pediatric essential vision benefits even if you do not have children.
  • Your health insurance policy must cover the pediatric vision EHB, even if you have separate stand-alone vision coverage.
  • No one has to take vision (or dental) for kids if it’s offered as a standalone plan. It has to be offered, but you don’t have to take it. If it’s part of a plan, and that plan is offered to children, then there is no way to remove it from the plan.

What is Vision Insurance?

Vision insurance is a type of coverage that entitles you to certain eye care benefits.  Typical benefits include

  • routine eye exams
  • discounts for the purchase of eyeglasses and contact lenses
  • discounts on refractive surgery (such as LASIK and PRK)

There are three main types of vision insurance plans:

Indemnity Health Insurance is a traditional insurance plan which allows policyholders to choose which medical providers they access.

Health Maintenance Organization (HMO) is a network of healthcare providers which provide policyholders with discounted rates.  However, policyholders’ access to care is restricted to the providers within the HMO.

Preferred Provider Organization (PPO) is a group of providers much like an HMO, except that policyholders have the option of paying more to receive care from medical practitioners outside of the PPO’s network.

Is Vision Insurance Required?

Yes, but only for children.  ObamaCare requires coverage for basic pediatric eye care services, but vision insurance for adults (19 or older) is not mandated by the ACA.

Child Vision Coverage

Pediatric eye care for dependents under 19 must be covered in any qualified healthcare plan that you buy in the Federal Exchange or a State Health Insurance Marketplace.

At the very least, this vision insurance will cover the following services:

  • Annual vision examinations
  • Glasses lenses
  • Glasses frames
  • Contact lenses in place of glasses

It’s important to know that pediatric vision services are not designated as a preventative by the ACA.  As a result, your marketplace plan may require you to have met your deductible before it covers pediatric vision services.

How Can I Get Adult Vision Coverage?

If you want eye care coverage as an adult, you have two options.  You can choose a marketplace health insurance plan that includes vision services in your medical coverage or you can purchase a separate stand-alone vision plan.

Can I Apply Tax Credits to Vision Coverage?

You can apply tax credits if vision is part of your Marketplace health plan. If you get a standalone plan you can’t.

Marketplace Plans and Eye Care Coverage

One option for those who want vision insurance is to buy a marketplace health plan which covers adult eye care services.

You must be careful when buying a marketplace plan that covers eye care services.  Such combined policies require you to pay only one premium, so often they may seem cheaper than buying a stand-alone vision plan.  However, these plans often have a large combined deductible which would have to be met before vision services are payed for.

When looking at marketplace vision insurance options, be sure to fully understand how each plan treats vision services.  Before selecting a plan, make sure you know all of the following:

  • specific eye care services covered, copayments, and reimbursement percentage levels
  • the deductible you must meet before non-preventative services are covered
  • the waiting period before you can use vision benefits
  • whether there are exclusions or conditions for vision coverage
  • whether the out-of-pocket maximum applies separately to vision or if only the medical out-of-pocket applies

For more information on selecting a health insurance plan with eye care coverage, see this guide by the Americas Group.

Cost Sharing for Vision

Vision and dental coverage can be underwhelming due to the way cost sharing works (maximums equal annual dollar limits, not the point where all services are covered. The opposite of regular health coverage!) Typically only routine care is covered by your vision or dental plan in a cost effective way, those who have held policies longer may earn better cost coverage. Also higher end plans may offer better cost sharing.

Excepted Benefits and Vision

  • Excepted benefits are benefit products that are designed to supplement comprehensive medical coverage.
  • For plans where dental and vision are included: If dental and vision are considered excepted benefits, they do not accumulate with medical toward the OOP maximums.
  • Excepted dental and vision benefits are exempt from most PPACA and HIPAA requirements that apply to medical plans.

Stand-Alone Vision Plans

Stand-alone vision insurance is coverage you can buy specifically for eye care services.  This is separate from your health insurance.

You must go to a private insurance provider or broker in order to buy a stand-alone plan since they are not offered on the federal marketplace or state insurance exchanges.

In some state exchanges, vision plan companies have partnered with qualified health plans to administer the medical plan’s vision benefits.  In this case, you can buy a vision plan along with your marketplace health insurance even though they will still be separate policies.

In order to avoid the ObamaCare tax penalty, your medical plan must cover pediatric vision even if you have a stand-alone plan that provides the same child eye care benefits.

Do the New ObamaCare Rights Apply to my Vision Plan?

The Affordable Care Act offers many new healthcare rights, benefits and protections.  Whether or not these apply to your vision plan depends on what type of coverage you have.

Many of the PPACA’s healthcare reform provisions do not apply to stand-alone vision plans since these policies are separate from your health insurance. For example, annual and lifetime dollar limits are not banned on stand-alone eye care plans.

Many of ObamaCare’s rights do apply to your vision benefits if they are an engrained part of your Marketplace health insurance (although not all the protections will apply if vision is considered an excepted benefit.

The provisions also do not apply if you are purchasing supplemental vision coverage separate from your health insurance (even if you are purchasing it on a state or federal Marketplace).

With employer-based health insurance, annual and lifetime dollar limits may exist if:

  • your eye care benefits are provided under a separate policy or contract
  • you have a right to elect not to receive the coverage (adult individual coverage, or family plans without children on them)
  • you must pay an additional premium if you elect to receive vision benefits

Can I get Cost Assistance with my Vision Plan?

In general, cost assistance applies only to medical coverage and not to vision insurance.  However, if your marketplace plan includes eye care coverage, you will only have one premium and you be able to apply premium tax credits.  You cannot receive cost assistance for stand-alone vision plans.

Can I Cancel My Vision Plan?

You can cancel a stand-alone vision plan at any time by not making payments on your vision insurance premium.  However, if you have a health insurance plan that includes eye care coverage, you can switch to a different plan during open enrollment but can’t drop the vision coverage without dropping the whole plan.