Does Insurance Cover Scleral Lenses?

Scleral lenses offer significant relief for individuals with complex eye conditions. Insurance coverage is not always straightforward, depending on medical necessity and your plan. This article guides you through understanding these complexities.

Factors Influencing Coverage Decisions

Insurance coverage for scleral lenses primarily hinges on demonstrating medical necessity, meaning lenses must be prescribed as treatment for a specific medical condition rather than routine vision correction. Common qualifying conditions include keratoconus, severe dry eye syndrome, corneal irregularities from injury or surgery, and other ocular surface diseases like Sjogren’s syndrome or Stevens-Johnson syndrome. Documentation must clearly indicate that standard corrective measures cannot adequately correct vision or manage the condition.

Medical insurance plans cover services and devices that treat medical conditions, potentially covering scleral lenses when medically necessary. Vision insurance plans typically focus on routine eye exams and eyewear purchases. Some vision plans may offer benefits for medically necessary contact lenses, but reimbursement for specialized lenses like sclerals can be limited.

Comprehensive documentation from an eye care professional is essential to support a claim for medical necessity, including specific medical diagnoses (ICD-10 codes) and professional service codes (CPT codes) for fitting scleral lenses. In-network versus out-of-network providers can also affect coverage levels and out-of-pocket expenses.

Understanding Your Specific Insurance Policy

To determine potential coverage, investigate your insurance policy by reviewing your Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy handbook. These documents outline covered services, exclusions, and your cost-sharing responsibilities. The SBC helps compare different plans by presenting information on costs, benefits, and coverage limitations.

Contacting your insurance company’s member services department is important to clarify coverage. Inquire about precise requirements for establishing medical necessity and if pre-authorization is required. Pre-authorization is an approval from your insurance company required before certain medical services or devices are covered, allowing the insurer to evaluate medical necessity and cost-effectiveness.

During this conversation, gain a clear understanding of your financial responsibilities. This includes your deductible, the amount you must pay for covered services before insurance begins to pay. Your copayment is a fixed dollar amount you pay for a service, while coinsurance is a percentage of the cost you pay after meeting your deductible. All these payments contribute to your out-of-pocket maximum, the annual limit on what you pay for covered healthcare services, after which your insurer covers 100% of in-network services for the remainder of the plan year. Premiums and costs for non-covered services or out-of-network care generally do not count towards this maximum.

Navigating the Coverage and Appeals Process

After gathering policy information, prepare necessary documentation to support your claim. Your eye care professional will provide a comprehensive prescription and detailed medical records justifying medical necessity, including results from relevant diagnostic tests and evidence of previous treatment failures with standard glasses or conventional contact lenses.

If pre-authorization is required, your eye care provider will typically submit the request. This includes patient information, relevant diagnosis (ICD-10) and procedure (CPT) codes, and clinical notes substantiating medical necessity. Approval or denial timelines vary, often ranging from a few business days to several weeks.

Once you receive your scleral lenses, your provider will submit a claim for reimbursement. You will then receive an Explanation of Benefits (EOB) from your insurer, detailing covered services, the amount paid by insurance, and any remaining balance you are responsible for. This document is not a bill, but it clarifies how your claim was processed.

Should your claim or pre-authorization request be denied, you have the right to appeal. The first step is an internal appeal, typically filed within a certain timeframe of receiving the denial notice. For this, submit a formal letter with supporting documentation like the denial letter, prior correspondence, original medical bills, and additional medical records or a letter of medical necessity from your eye care provider. If unsuccessful, pursue an external review, often through an Independent Review Organization (IRO).

Exploring Alternative Financial Assistance

If insurance coverage for scleral lenses is denied or insufficient, several alternative avenues for financial assistance exist. Many eye care providers may offer in-house payment plans. These plans can help manage the expense by breaking down the total cost into more affordable monthly installments.

Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer tax-advantaged ways to pay for qualified medical expenses, including scleral lenses. Funds contributed to these accounts are pre-tax, reducing your taxable income. Scleral lenses are considered eligible medical expenses by the Internal Revenue Service (IRS), as outlined in IRS Publication 502. Using an FSA or HSA can effectively lower the out-of-pocket cost of the lenses.

Some scleral lens manufacturers or non-profit organizations may offer patient assistance programs or rebates to help offset costs. These programs can provide discounts or financial aid based on specific eligibility criteria. Researching directly with lens manufacturers or inquiring through your eye care professional can reveal such opportunities.

Additionally, various charitable organizations nationwide are dedicated to assisting individuals with vision care needs.

• Prevent Blindness
• Lions Clubs International
• EyeCare America
• New Eyes
• OneSight
• ReSpectacle
• VSP Eyes of Hope

These organizations provide different forms of support, from financial aid to connecting patients with free or reduced-cost services. They often have specific eligibility requirements, so exploring their websites or contacting them directly is recommended.