Optical Insurance: What Does It Cover?

What is optical insurance?

Optical insurance falls under the Optical Benefit, an optional benefit in a health insurance policy. As defined by Hong Kong’s Voluntary Health Insurance Scheme (VHIS), the Optical Benefit covers eye examinations, as well as prescription glasses, prescription contact lenses, and prescription sunglasses. The Optical Benefit is sometimes referred to as the Vision Benefit or Eyecare Benefit. It is usually bundled with the Dental Benefit.

Local health insurance plans rarely cover eye exams and prescription glasses and contact lenses, but more comprehensive plans and international plans often include coverage for one eye exam a year, as well as glasses and contacts – with an annual limit.

Eye doctors: Optometrists vs. ophthalmologists

There are two types of eye doctors who can perform eye exams and provide optical care: optometrists and ophthalmologists. But they are not the same.

The Optical Benefit typically refers to services provided by optometrists. More specialized care involving medicine and surgery is provided by ophthalmologists and covered under Specialist Consultations.

An optometrist...

• Is a medical professional
• Specializes in primary vision care
• Performs eye exams; vision correction; diagnosis, treatment, and management of vision changes; prescription of lenses for spectacles and contact lenses
• Attended optometry school
• Has a Professional Diploma in Optometry, Bachelor of Optometry, Doctor of Optometry, or Higher Certificate in Optometry from a recognized institution, or a Certification from the Optometrists Board

An ophthalmologist...

• Is a medical doctor
• Specializes in eye medicine and surgery
• Performs diagnosis and treatment of eye diseases; eye surgery; vision correction; prescription of lenses for spectacles and contact lenses
• Attended medical school
• Doctor of Medicine in Ophthalmology - M.D. (Ophthalmology)

What eye care is covered by insurance?

Coverage for eye examinations, prescription glasses, and prescription contact lenses

These are covered under the Optical Benefit. During an eye exam, you go through a series of tests performed by an optometrist or ophthalmologist to assess the clarity of your vision (visual acuity); ability to discern colors; depth perception; what lens prescription you would need to correct shortsightedness, astigmatism, or farsightedness (refraction test); and other things relating to your vision.

Local plans usually don’t cover exams or prescription glasses or contact lenses, but some more comprehensive plans and international plans have an Optical Benefit that can be used towards one eye exam per year and the reimbursement of prescription glasses or contacts. You’ll want to pay attention to your policy’s annual sub-limits, which can range from HK$ 1,000 to HK$ 5,800.

Coverage for ophthalmologist consultations and eye surgery

These are covered under Doctor Specialist Fees or Specialist Consultations and Surgical Benefits. Generally, high-end health insurance plans will cover ophthalmologist consultations and surgical fees in full with no sub-limit. Local plans, on the other hand, will have some limits.

Note, however, that surgery must be deemed medically necessary by your insurance provider to be eligible for reimbursement. This means LASIK procedures are rarely covered by insurance.

You’ll also want to be aware of any plan sub-limits or waiting periods. For example, your plan may cover cataract surgery – but only after 120 days have passed since your insurance policy's start date, and only if it is an outpatient surgery (i.e., you do not have to stay overnight in the hospital as you would for inpatient surgery).

If you’re not sure whether your insurer will cover a certain surgical procedure, then it’s best to talk to your broker or advisor for guidance.