AOA Overview of Essential Benefits Announcement by HHS

December 18, 2011

Reprint of 12/16 advocacy message from Jon Hymes, AOA Washington Office Director – 1-800-365-2219 / jfhymes@aoa.org

This is an update from the AOA explaining a significant regulatory action taken today by the U.S. Department of Health and Human Services (HHS) to implement a key optometry-backed provision of the 2010 health care overhaul law.  The new law, which seeks to expand health coverage to more than 30 million currently uninsured Americans, specifically designated pediatric vision care as an essential benefit and authorized HHS to define what it would include.

Since the law’s enactment 20 months ago, AOA doctors and staff have been meeting with White House and HHS officials, including Secretary Kathleen Sebelius, in Washington, DC and in large public “listening sessions” around the country, to press for a benefit based on direct access to optometric care for America’s children and covering a comprehensive eye exam and follow-up care, including materials.   At the same time, insurers, organized medicine and other groups with an anti-optometry agenda have actively sought a screening-based benefit and to try to impose limits on patient access to ODs.    However, due to the efforts of optometry’s supporters in Congress and the AOA’s clear success in being heard in the regulatory process, optometric care is key step closer to being recognized as essential at the Federal level.

Today, in a much anticipated announcement, HHS essentially acknowledged that “pediatric vision care” in the new health care law is centered on a comprehensive eye examination, not a screening offered alone or as part of a “well child” office visit.  However, HHS also largely directed states to determine the specific essential benefit package for health insurance offered to small group and individual markets based on market-leading plans within each state, with a default to the Federal employees benefit plans.  The AOA believes significant ongoing federal and state advocacy is necessary to ensure that “pediatric vision care” will not be downgraded to less than a comprehensive eye examination for the millions of newly insured Americans under these plans starting in 2014.

– Process:  This is a “pre-rule” from the HHS Center for Consumer Information and Insurance Oversight run by former Maryland insurance commissioner Steve Larsen.  HHS is asking for comments by January 31.  This bulletin is guidance on potential future regulations for “covered services.” HHS will address cost sharing and actuarial valuation separately.

– The Impact:  Essential benefits must be covered by non-grandfathered individual and small group plans (in and outside the state health insurance exchanges), as well as Medicaid benchmark and benchmark-equivalent plans and Basic Health Programs.

 The Federal Role: HHS must define essential benefits equal to a typical employer plan but must not make coverage or reimbursement decisions.  For pediatric vision, HHS studied the Federal Employees Dental/Vision Insurance Program (FEDVIP).  FEDVIP is a standalone vision and dental program where eligible Federal employees pay the full cost of their “excepted benefits” coverage.  The 2010 FEDVIP plan with the highest enrollment covers “routine” eye exams with refraction, and corrective lenses and contact lenses.  In some cases a medical plan provides the coverage.

The State Role:  HHS will allow states to choose their own essential benefits package using an existing plan as a benchmark.  The essential benefits must be “substantially equal” to the benefits of the chosen plan.  The 10 choices for each state are:

•                 One of the three largest small group plans in the state;

•                 One of the three largest state employee health plans;

•                 One of the three largest federal employee health plan options;

•                 The largest HMO plan offered in the state’s commercial market.

If a state chooses a benchmark plan that does not cover the category of pediatric vision care, then HHS is considering having the essential pediatric vision care benefit default to the FEDVIP plan with the largest enrollment.  Unlike pediatric oral care, HHS does not offer states to default to their CHIP plan because CHIP does not require vision services.  HHS is considering allowing the plans to define pediatric vision care services and report to HHS what the coverage is, with HHS retaining the option to further define the benefit.

HHS acknowledges that in the current market pediatric vision care is available from a mix of comprehensive health plans and separate standalone plans.  FEDVIP relies on standalone vision plans to administer the benefit but HHS does not (and in most cases cannot) require that the essential benefits be provided by a standalone plan.  The essential benefits will be provided by new plans for new markets of millions of covered lives, including 9-10 million children who previously did not have health insurance, much less coverage for vision care.

HHS intends for health plans to have some flexibility to adjust benefits including the specific services covered and any quantitative limits on that coverage.  HHS is considering “substitution” within an essential benefit category or across essential benefit categories.

HHS estimates the states have 1,150 benefit mandates and 450 provider mandates.  States will have some obligations to fund mandates that are not essential health benefits, so states will have 2014 and 2015 to coordinate their mandates with their chosen essential benefits benchmark.


– The AOA Role:  The leadership of the AOA, the AOA Advocacy Group volunteers (including the Federal Relations Committee, Third Party Center and State Government Relations Center) and other concerned doctors will continue to advocate collectively for appropriate benchmark benefits for pediatric vision care by assessing state options, assisting with state affiliate strategies, continuing pressure on HHS to ensure that no state will be able to offer an inadequate pediatric vision benefit, and member and public education.

– The State Affiliate Role:  Full engagement in state-level implementation of the new health care law and full delegations to the upcoming AOA Super Advocacy Meetings in Washington, DC, April 1-3 (AOA Congressional Advocacy Conference and AOA State Government and Third Party National Conference).

The AOA will continue to review the materials HHS released today, provide further updates and begin to develop substantive comments aimed at solidifying patient access gains.   If you have any questions or comments, or if doctors want to know how they can support the AOA and state affiliate efforts on implementation of the health care law, please don’t hesitate to contact me.

Thank you.


Jon Hymes, AOA Washington Office Director – 1-800-365-2219 / jfhymes@aoa.org

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