Can You Have Two Eye Insurance Plans?

Eye insurance plans typically cover routine eye examinations, prescription eyewear, and contact lenses. Many individuals receive vision benefits through their employer, while others might secure individual plans. It is generally permissible to be covered by more than one eye insurance plan, allowing for potentially broader coverage of vision care expenses.

Understanding Coordination of Benefits

When an individual has more than one eye insurance plan, a process known as Coordination of Benefits (COB) comes into effect. The purpose of COB is to ensure that a policyholder receives the maximum allowable benefits from both plans without duplicating payments for the same service. This process involves determining which plan is considered the “primary” insurer and which is the “secondary” insurer. The primary plan is responsible for paying its benefits first, as if no other insurance coverage exists. After the primary plan processes the claim, the secondary plan reviews the remaining balance and may cover eligible expenses not fully paid by the primary plan, often reducing out-of-pocket costs.

Determining which plan is primary and which is secondary follows specific rules. For dependent children covered under both parents’ vision plans, the “Birthday Rule” is commonly applied. Under this rule, the plan of the parent whose birthday falls earlier in the calendar year is designated as the primary insurer.

Another common scenario involves individuals covered by both an employer-sponsored plan and an individual plan, or by their own employer’s plan and a spouse’s employer-sponsored plan. In these situations, the plan covering the individual as an employee is typically considered primary. The plan covering the individual as a dependent, such as through a spouse, would then be secondary. If no other specific rules apply, the plan that has covered the policyholder for the longest continuous period might be designated as primary.

Coordination of Benefits also applies when an eye care service could fall under both vision and medical insurance. Vision plans typically cover routine eye exams and vision correction, like glasses and contacts. Conversely, medical insurance covers eye care related to medical conditions, such as glaucoma, infections, or injuries. When a visit involves both routine vision care and a medical eye issue, the medical insurance is generally billed first as the primary payer. The vision plan may then act as the secondary insurer for any remaining eligible costs related to routine services, such as refractions.

Navigating Dual Coverage Claims

When utilizing two eye insurance plans, policyholders should inform their eye care provider about both coverages at the time of service. Presenting both insurance cards allows the provider’s office to initiate the coordination of benefits process. The provider’s billing department typically handles the submission of claims to the appropriate insurers. They will first submit the claim to the primary insurance plan.

After the primary plan has processed the claim and issued an Explanation of Benefits (EOB), the remaining balance is then submitted to the secondary insurance plan. The secondary plan will review the claim, taking into account the payment made by the primary insurer. It may then cover additional eligible expenses, such as deductibles, copayments, or coinsurance that remained after the primary plan’s payment. However, it is important to understand that coordination of benefits does not guarantee that all out-of-pocket expenses will be fully covered. The combined payments from both plans will not exceed the total cost of the services.

Policyholders should be aware of how deductibles and copayments function with dual coverage. While copayments generally do not count towards meeting a deductible, a secondary plan may help cover these costs. The specific coverage details depend on the terms of each individual policy. For instance, if the primary plan has a deductible that is not met, the secondary plan may contribute towards that deductible or other remaining costs, depending on its own benefit structure.