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AOA’s patient access message key as HHS releases plan for pediatric essential eye health benefit

January 4, 2013

The federal government recently released its much-anticipated implementation plan for the new health care law’s pediatric essential eye health benefit. This is a leap forward for the AOA and affiliate advocacy efforts that made healthy vision a top national health care priority and expanded inclusion of optometrists on medical panels.

The Nov. 26 U.S. Department of Health & Human Services (HHS) special regulatory announcement is expected to have a significant impact on optometry and patients in communities across the country, the AOA Advocacy Group said. The recently published guidance on the Affordable Care Act’s (ACA) standard set of benefits reaffirms that:

  • 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 are permitted to partner with health plans in the offering of fully integrated eye health care coverage inside and outside of state exchanges.

Consumers may continue to purchase supplemental adult vision coverage as they have always done outside of the exchanges, or possibly through new supplemental markets connected to 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,” said AOA President Ron Hopping, O.D., MPH. “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, state 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,” added Dr. Hopping. “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.)

Since the health law’s enactment in 2010, AOA doctors and staff have been meeting with White House and HHS officials, including Secretary Kathleen Sebelius, 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 tried 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 moving ever closer to being recognized as essential at the federal level.

For more information on AOA advocacy and to learn more about how you can get involved, including by joining the AOA Federal Keyperson Program and investing in AOA-PAC, contact the AOA Washington office at 800-365-2219 or email ImpactWashingtonDC@aoa.org.

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