What’s in a plan? How going over the small print can make you a better broker

eye care in Tulsa
January 27, 2022
James Ashford

Are you considering offering your clients a new plan for eye care in Tulsa or any city in the nation for that matter? Before you do, make sure you understand all of that plan’s requirements. In other words, if you expect your clients to read the fine print, you need to do that, too.

Why does this matter? It matters because all too often brokers craft their descriptions without knowing what’s in the fine print. By helping your clients understand any plans they are considering, you can use your expertise in reading these documents as an additional sales tool. When you help your clients understand a potential purchase, you can also ensure that they maximize the value they offer to their employees for eye care in Tulsa, OK and the rest of the country beyond.

How transparent is the plan?

There’s a strange little concept in law called a “pregnant negative.” It means that if someone refuses to deny an allegation in its entirety, that implies that part or most of the allegation is likely true. What happens often is, vision insurance plans say their plan offers unlimited tests, but employees find themselves still getting charged for them.

You want to make sure your employer prospects understand whether the plan they are considering requires the use of specific labs or suppliers, or whether providers can use any labs or suppliers they prefer. Once again, this is a matter of credibility — your credibility with your client and the client’s credibility with their staff. Larger vision plans may also require that your clients carry their products in order to receive the highest allowances. For instance, some vision insurance companies give discounts or higher allowances when a patient chooses their frame line or lens materials. The problem is when the doctors are forced to use these lab networks or materials is that the insurance company that is offering the higher discount or frame allowance owns the materials and sets the pricing.

Optometry versus ophthalmology

We all know that there are differences between optometry and ophthalmology. In simple terms, optometry deals with vision correction, while ophthalmology deals medically with eye injuries or illnesses. It’s important, however, to make sure that your prospects understand the difference, as well as the relationship between the two. Optometry can help discover physical problems, and that benefit should not be downplayed. Indeed, the optometrist can even help coordinate care when patients with multiple diseases are seeing multiple specialists involving possible drug interactions and surgeries.

Who pays for what?

Some of the larger plans lead employers to coordinate with health insurance providers to cover some offered services. There is a downside to this, which you need to make clear to your prospects. The health insurance deductible will apply to whatever care that the health insurance covers. If the vision plan also has a deductible, the client’s employees might even have to pay two deductibles. Finally, sometimes the employee has to make two separate claims because the vision insurance will only pay if health insurance denies the claim. Consider this real-world scenario for your practice: A woman makes an appointment using her vision insurance and during the exam, the doctor sees a medical issue such as cataracts, glaucoma, diabetes, or even dry-eye and by law has to file the claim with the woman’s health insurance. Now the woman has to pay the Specialty Doctor copay and loses the benefit of that eye exam with her vision insurance because they coordinate benefits and if the care is charged to medical they will deny the claim for vision. You may be able to help your employer’s clients avoid this problem.

Is there a limited network of providers?

Many plans limit the providers your clients’ personnel can see. If there is a network, is it large enough to fully service your clients’ personnel? Will the cost for an out-of-network service be catastrophic? Will pre-approval for out-of-network providers be required, and if so, will it be difficult to get?

Impact of fees on providers

Has the fee schedule remained the same for years? Is this shrinking the provider network? Does that fee schedule mean that your company’s clients don’t really get the network coverage they expect? For example, some vision insurance plans have multiple networks. They have networks of doctors that accept higher discounts and those who refuse to do so. Typically the network with the lower reimbursements will shrink over time. What the industry is seeing is that many of the larger insurance companies are losing Independent Optometrists and gaining retail optometry locations.

What gets covered?

Vision plans used to be pretty uniform. They included an annual exam, annual glasses, and annual contacts. Nowadays, things are a lot more complex. Check out how often employees can get exams. What kinds of exams does the plan cover? Are there limits on materials, and have those limits kept pace with current costs? Do employees have to purchase from a restricted group? Does the plan cover any other or “extra” services? Does the plan include LASIK, special lenses or lens coatings (like scratch-resistant or anti-reflective coatings), fitting fees for contacts, and similar items?

Who gets covered?

Does the plan your client is considering allowing employees to add their dependents? Is the cost of doing so prohibitively expensive for those employees? ACA plans have to include vision screenings for children but your clients may want to offer a plan with more than minimal care for employees’ children. Make sure you can explain what the plan actually provides or makes available for dependents. If a client’s vision plan coordinates benefits and their health plan, as many do today, includes a vision exam, does the employee lose the value of the eye exam with their vision insurance, which is typically the case?

Value for the money

Help your prospects understand what they are getting for their money. Does the plan have high deductibles before it pays anything? How much are co-pays? Given these and the amount of the benefits payable, are employees really gaining anything from having this plan? Help your clients understand the benefit they are offering to their employees so that they can happily help to sell participation to them. One trap many brokers fall into is to offer a vision plan that has the lowest monthly premium instead of looking at the Total Out-Of-Pocket (TOOP) Costs. Vision Care Direct has a tool that lets you easily calculate TOOP.

Let Vision Care Direct help you offer eye care in Tulsa, OK and the rest of the country beyond

For your clients seeking to offer eye care in Tulsa, OK, or elsewhere, you are a skilled and knowledgeable professional. Your prospects want to offer the best plans they can to their employees. You want to make sure those plans are affordable, available, and, most of all, clearly understandable to your clients. You are the expert who can thoroughly explain a plan to your clients. VCD of Oklahoma can help you provide your clients with the plans they are seeking.

Not sure where to get started with recommending self-funded plans? Vision Care Direct of Oklahoma is pre-paid plan provider with and extensive of specialists who deliver eye care in Tulsa and nationwide with excellent value for employers and plan recipients.

Find out more about our self-funded plans and other flexible options.

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