AOA sees early gains as HHS releases essential health benefits proposal

February 6, 2012

In the closing days of 2011, the U.S. Department of Health & Human Services (HHS) released much-anticipated details of a substantial regulatory step that the agency is planning to take toward implementing a key optometry-backed provision of the 2010 health care overhaul law. 

After months of determined advocacy in the nation’s capital and in cities and towns across the nation, the HHS ultimately acknowledged in its recent essential health benefits proposal that the “pediatric vision care” essential health benefit would be centered on a comprehensive eye examination and not a screening offered alone or as part of a “well child” office visit.

Under the new law, the HHS has been charged with defining and updating the 10 categories of essential health benefits, including the AOA-backed “pediatric vision care” benefit.

Additionally, the law mandates that the agency ensure that essential health benefits are at least equal to the scope of benefits offered under a typical employer plan.

Starting in 2014, essential health benefits must be covered by non-grandfathered individual and small group plans within the state health insurance exchanges, non-grandfathered individual and small group plans outside of state health insurance exchanges, as well as Medicaid benchmark and benchmark-equivalent plans, and Basic Health Programs.

The AOA now believes that 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, including 9 to 10 million children who previously did not have health insurance, much less coverage for vision care.

Since the law’s enactment, AOA doctors and staff have been meeting with White House and HHS officials in Washington, D.C., 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.  

But, 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 a key step closer to being recognized as essential at the federal level.

Nevertheless, while the HHS announcement is considered a first-round win for AOA and its Capitol Hill partners, the agency did fall short by largely directing states to determine the specific essential health 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.

In its initial plan, the HHS proposed to allow states to choose their own essential benefits package using an existing plan as a benchmark.

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; or the largest health maintenance organization (HMO) plan offered in the state’s commercial market.

The HHS is considering allowing the plans to define pediatric vision care services and report to the HHS what the coverage is, with the HHS retaining the option to further define the benefit.

However, if a state chooses a benchmark plan that does not cover the category of pediatric vision care, then the HHS is considering having the essential pediatric vision care benefit default to the Federal Employees Dental/Vision Insurance Program (FEDVIP) with the largest enrollment. 

Importantly, HHS notes in its proposal that the FEDVIP plan with the highest enrollment covers “routine” eye exams with refraction, and corrective lenses and contact lenses.

Additionally, the HHS notes that essential benefits must be “substantially equal” to the benefits of the chosen plan. 

Going forward, AOA volunteers and staff 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 the HHS to ensure that no state will be able to offer an inadequate pediatric vision benefit, and member and public education.

As for state affiliates, it is now more critical than ever to have full engagement in state-level implementation of the new health care law and full delegations to the upcoming AOA Super Advocacy Meetings in Washington, D.C., April 1-3 (AOA Congressional Advocacy Conference and AOA State Government and Third Party National Conference).

To view Washington office Director Jon Hymes’ full overview of the recent HHS announcement, please visit http://newsfromaoa.org/2011/12/18/aoa-overview-of-essential-benefits-announcement-by-hhs/.

AOA members looking to become more involved in federal advocacy and those seeking more information on the upcoming AOA Super Advocacy Meeting should contact the AOA Washington office at 800-365-2219 or ImpactWashingtonDC@aoa.org.

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