Marketplaces to offer affordable options

June 13, 2013

The reform law establishes state health insurance marketplaces (or exchanges) through which patients can find affordable health insurance (for most who are not covered through existing channels such as private health insurance companies, employer-based health plans or public programs such as Medicare or Medicaid).

The new exchanges and other initiatives authorized under the ACA will provide coverage for up to 30 million Americans, according to estimates by the Congressional Budget Office (CBO) and the staff of the congressional Joint Committee on Taxation (JCT).

Under the health reform law, all qualified health plans (QHP) offered through federally authorized health insurance exchanges must, at a minimum, cover the services outlined in a new, federally defined essential health benefits package. In addition, all insurers offering small group and individual insurance products outside the exchanges must offer coverage for each of the essential health benefits.

Pediatric eye and vision care, including comprehensive examinations, is included in the essential benefit package as the result of efforts by the AOA Advocacy Group (see AOA News, March 2010). Pediatric vision care coverage under the health exchange plans will be modeled after a “benchmark” plan for each state. There will be variations between the benefits in each state, but most will cover an annual exam with a materials benefit.

QHPs participating in the exchange will have the option to add adult vision coverage as well.

Optometrists are guaranteed the opportunity to provide these eye and vision care services under the Harkin Amendment, a first-of-its-kind federal provider nondiscrimination provision included in the health reform law thanks to AOA Advocacy Group efforts (see AOA News, March 2010).

However, optometrists who wish to provide care under the QHPs should prepare to apply for participating provider status on health plan provider panels, the AOA Advocacy Group advised.

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