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AOA’s Patient Access Message Takes Hold in Federal Plan for Health Law Implementation

November 20, 2012

In a leap forward for AOA and affiliate advocacy efforts designed to make healthy vision a top national health care priority and to expand inclusion of optometrists on medical panels, the Federal Government today released its implementation plan for the new health care law’s pediatric essential eye health benefit. Here’s an overview of the U.S. Department of Health and Human Services’ special regulatory announcement and its expected impact on optometry:

  • Millions of children will gain health insurance coverage through age 18 that includes direct access to their local optometrist for a comprehensive eye exam and treatment, including medical eye care.
  • Pediatric eye health care is confirmed as an “Essential Health Benefit,” and must be offered by all new health plans as a distinct benefit from well child care.
  • Pediatric eye health care is defined as an annual comprehensive eye exam and treatment, including medical eye care.
  • All new health plans – both inside and outside of state exchanges – are required to provide fully integrated coverage for pediatric eye health care and must recognize optometrists as providers of medical eye care.
  • Vision plans, including VSP, are permitted to partner with health plans in the offering of fully integrated eye health care coverage inside and outside of state exchanges.

In taking this action, the Obama administration accepted the AOA’s longstanding position on healthy vision for America’s children and rejected lobbying by ophthalmologists, pediatricians and their organized medicine allies who wanted pediatric vision care to be based on a screening or limited to an element of well child care. The administration also said “NO” to a stand-alone plan carve-out of vision that would have segregated a full pediatric eye health benefit, downgraded it from mandatory to optional status, and imposed new barriers to OD-provided medical eye care.

In the weeks ahead, states officials will also be making important implementation decisions, and continued advocacy by optometry will be needed to lock-in patient access gains envisioned under Federal law. To make certain that ODs will play a leading role in delivering the full range of eye health and vision care services, including medical eye care, to the millions more children who will soon gain coverage, the AOA is urging affiliates to advocate for the following directive to be adopted by or included in state exchanges:

“The pediatric vision benefit includes a comprehensive eye evaluation, and if medically indicated, dilation and refraction for prescription glasses as well as other medically indicated vision services. This type of eye care is primarily provided by optometrists. As a result, optometrists must be included in Qualified Health Plan networks in order to meet the requirement to provide pediatric vision care.”

(California Health Benefit Exchange Board, August 2012, based on input by the California Optometric Association and an independent review of Federal law.)

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