What are covered services?
Covered services are services covered by the plan. No vision plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services. Also, note that some medical procedures associated with the eyes may be covered by another health care plan, in which case they are not eligible for coverage under this vision plan. See your plan materials for a complete list.
What is an “allowable amount” (also referred to as “U&C amount” or “R&C amount”)?
With a plan designed to cover a percentage of eligible expenses, you need to know about the allowable, U&C or R&C amount. Plans use these different terms, but they mean the same thing. This is the amount usually charged for a given service by most providers in your area. This amount is determined by your vision care plan as the fair value for a given procedure or expense.
If your provider charges you more than this amount, you will not only be responsible for any deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept may not apply for plans where you need to use network providers, because network providers have agreed to negotiated fees that are, by definition, allowable amounts. For example, suppose you receive a service for which the “U&C amount” is $100 but your provider charges you $110. The vision care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).
What is a copayment?
If your plan is designed so you pay a fixed amount at the time you receive services, that amount is called your copayment.
What is coinsurance?
When you and the plan each pay a percentage of eligible expenses, the percentage you pay is called your coinsurance. With coinsurance, after you satisfy any deductible, the plan will reimburse you for the plan’s share of your eligible expenses and you will pay the balance.
When do I need to file a claim form?
If your plan requires you to use network providers, you may not need to file a claim form when you do. If your plan does not require you to use network providers, your provider will probably bill you directly. You then submit a claim form to be reimbursed. You will be reimbursed for the plan’s part of the bill, after you have met the plan’s deductible, if any. To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another plan, be sure to include a copy with your claim form. Depending on the type of care you need, you may want to call both your vision plan and any medical plan if you need care while traveling.
What are the advantages of seeing a network provider?
If your vision plan requires you to use a network provider
- You may not need to pay a deductible (the flat amount of eligible expenses you pay out of your pocket before the plan begins to pay benefits).
- Your provider may submit claim forms for you.
- Your provider agrees to accept negotiated fees for certain services, which are generally lower than standard fees.
- Other plans do not require you to use particular vision care providers. See your plan materials for details.
Why do we have a vision plan?
The vision plan encourages you and eligible family members to take care of your eyesight. It helps cover preventive services, such as eye exams, as well as the cost of certain qualified treatments.