Best Insurance for Keratoconus
- May 16, 2021
Keratoconus patients wonder about the best insurance to get. Not only do you want to get the best care. You want to minimize the cost of ongoing specialized eye care.
Paying for keratoconus
Navigating third party payers can feel bewildering, particularly if you have keratoconus. Realize that both medical insurance and a vision wellness plan can help get you the keratoconus care that you need. At the risk of over simplifying, medical insurance is for surgery whereas vision plans are for specialty contact lenses.
Medical insurance is particularly valuable if you have worsening keratoconus. Medical insurance can defray the cost of undergoing corneal cross-linking surgery to slow or halt the disease. Upwards of 95% of medical insurances cover corneal cross-linking. Medical insurance is also valuable if your keratoconus is advanced to the level of needing corneal transplantation. By comparison, a vision plan can help you get the specialty contact lens prescribing needed for optimal vision.
Medical insurance for keratoconus
Medical insurance pays for services related to sickness, eye disease and surgery. For example, if you need corneal cross-linking or corneal transplantation, medical insurance applies. Historically, the purpose of insurance is to reduce the risk of incurring catastrophic costs related to death, disaster, and disability. For example, the out-of-pocket cost to undergo corneal transplantation is approximately $15,000 to $30,000. Relatively few individuals can pay for such an unplanned expense. Medical insurance helps to offset such big-ticket surprises.
Vision plans for keratoconus
The long-standing conundrum for keratoconus is that medical insurances generally fail to recognize how specialty contact lenses rehabilitate vision for keratoconus. Medical insurance decision-makers seem unfamiliar with keratoconus, even wondering why you need contact lenses and cannot use eyeglasses. This leaves specialty contact lens services and lenses as an out-of-pocket expense for many with keratoconus. The exception is if you have a group vision benefit plan. The National Keratoconus Foundation continues to educate medical insurances about keratoconus and the need for medically necessary contact lenses. Nevertheless, few medical insurances sufficiently cover the cost of specialty contact lens prescribing, even though contact lenses are usually more cost effective and successful in restoring vision than corneal transplantation in keratoconus.
Vision benefit plans like Vision Service Plan (VSP), EyeMed Vision Care, and Medical Eye Services, are wellness programs which provide coverage for routine eye health check-ups and savings on eyeglasses and contact lenses. Unlike true insurance, vision plans do not protect you from catastrophic financial ruin. Vison benefit plans do not pay for eye surgery, but some provide for “medically necessary contact lenses”, a stepped-up coverage for keratoconus.
Keratoconus does not always qualify for necessary contact lenses
Qualifying for medically necessary contact lenses varies from one vision plan to another. For example, with most EyeMed plans and Medical Eye Services, the severity of your keratoconus must meet specific criteria. Yet with most VSP coverage, the severity of keratoconus usually does not influence coverage of medically necessary contact lenses; even the mildest cases of keratoconus qualify. It is important that you are evaluated in a practice familiar with the nuances of necessary contact lens authorizations and navigating what is covered so that you do not get an after-visit surprise bill.
Covered does not usually mean in full
Bear in mind that if you are “covered” for medically necessary contact lenses, this does not usually mean covered in full. For example, with Medical Eye Services, if your keratoconus crosses their severity threshold for necessary contact lenses, expect only a few hundred dollars of coverage toward services and materials. This can leave you still with a significant remaining amount of out-of-pocket cost, up to several thousands of dollars each year. Other vision plans may provide much greater coverage for those that qualify, although there are usually still co-payments for services and contact lenses.
Individual vision plans do not cover medical contact lens care
While it is true that many VSP and EyeMed plans can provide significant coverage for specialty contact lens care for keratoconus, this only applies to group policies purchased through an employer. Do not rush to purchase a VSP Individual Plan or EyeMed Individual Plan if you have keratoconus without realizing that individual plans do not have necessary contact lens provisions. These individual plans specifically exclude coverage for necessary contact lenses. This is understandable because if individual vision plans paid out more than is funded through premiums, the plan would not remain financially solvent.
Select your provider carefully
To receive the best care for keratoconus, select your eye doctor first. Then check if your preferred doctor is in your insurance or vision plan network. Some networks do not offer adequate reimbursement for providers to give quality care. In these cases, the provider network may attract less experienced doctors including those that do not routinely care for keratoconus. Practices in lower-tier networks may also use older technology and cover less expensive contact lens treatment. A provider and practice that routinely manages keratoconus will likely have familiarity with billing necessary contact lens authorizations and use the latest technology to manage keratoconus. These practitioners will gravitate to participating in vision plan panels that allow them to sustainably provide quality care for keratoconus.
Take control of your keratoconus
If your plan does not include your preferred eye doctor, you may choose to go out of your network and take control of your own care. In these instances, paying out-of-pocket and selecting experience and expertise can often bring you a desirable outcome more efficiently. This can also save you money and frustration in the long run.
If you pay privately for your services and materials, you can set aside pre-tax money for your care – up to $2,750 in a flexible spending account (FSA) per year per employer – for qualified expenses to manage your keratoconus. Not every employer offers an FSA. If you do not have an FSA but you have a high-deductible health plan, you may be able to use a tax-advantaged health savings account (HSA) to help you resourcefully use your money to manage your keratoconus.