EyeMed Vision Care
Provider Type
- Physicians
- Participating Physician Groups (PPG)
Health Net contracts with Centene Vision Services to provide vision benefits to Health Net members whose coverage includes vision plan benefits. Centene Vision Services sub-delegates benefit administration to EyeMed Vision Care. EyeMed provides benefits for a routine vision exam and/or eyewear through their network of optometrists, dispensing opticians and optometric laboratories for employer and union groups as well as individual members (not covered through an employer group). Benefit coverage and benefit administration varies by plan:
- Exam only
- Materials only
- Exam and materials
Depending upon the plan the routine vision examination may be covered through their participating physician group (PPG) or primary care physician (PCP) or through EyeMed.
If the member requires eyeglasses, a prescription is written and the member may purchase eyewear from a list of participating dispensing opticians in California.
The optician bills EyeMed Vision Care for reimbursement. If the member selects standard lenses and frames, they do not owe the dispensing optician. If more costly items are selected, members are required to pay the amount in excess of those specified in the Schedule of Allowances under the member's Evidence of Coverage (EOC), or Certificate of Insurance (COI). The HMO member is required to obtain eyewear services only through participating providers.
Eye Care Network Responsibilities
The PCP or PPG are not responsible for referring Health Net members to EyeMed Vision Care for a refraction examination when applicable; however, PCPs or PPGs should be aware of which members have this benefit so they can direct the member to contact EyeMed Vision Care when appropriate.
If the EyeMed Vision Care provider finds a medical problem during the refraction examination, the provider must refer the member back to the PCP or PPG. If the medical condition is considered acute or emergency, the provider must call the PPG and direct the member back to the PCP immediately or to a hospital emergency department, if appropriate. For non-emergency conditions, the provider prepares and sends a report to the PCP or PPG identifying the problem and instructs the member to follow up with their PCP for further evaluation and treatment.
A member with a Health Net vision plan can request an appointment for a vision examination through the PPG.
Criteria for Vision Services
Eyewear services is not covered by individual family plans (IFP).
The HMO member is required to obtain eyewear services through participating providers. Refer to the member's Evidence of Coverage (EOC), Certificate of Insurance (COI) or Schedule of Benefits for additional information or contact Health Net vision plan.
A member with a Health Net vision plan can request an appointment for a vision examination through the participating physician group (PPG).