New health marketplaces taking shape: Find out the first steps for participation

June 13, 2013
The Massachusetts HealthConnector website is typical of the online insurance portals most health care exchanges will maintain to help uninsured find appropriate coverage.

The Massachusetts HealthConnector website is typical of the online insurance portals most health care exchanges will maintain to help uninsured find appropriate coverage.

Most of the major provisions of the federal Affordable Care Act of 2010 – better known as Obamacare – are set to go into effect Jan. 1, 2014. Yet, six months out, the reform law is still a source of concern for many optometrists.

The most common question is: what do optometrists need to do to provide care to the patients newly covered under health insurance plans created through health care reform?

The first step for optometrists is to identify the health insurance exchanges that will serve their respective states – and determine the type of exchange (see below).

A total of 51 health insurance marketplaces will be developed in the states and the District of Columbia: 18 state-based exchanges, 26 federally facilitated exchanges, and seven “partnership” exchanges, developed jointly by state and federal government.

The federal government has not yet announced the specifics on the federally facilitated exchanges that will serve more than half the nation. However, websites for all state-based and partnership exchanges can be accessed now on the “Your State Marketplace” page of the federal government’s Health Care Reform web portal at http://tinyurl.com/b69w2pm.

Optometrists can find contact information, the organizational structure for the exchanges, and in most cases, at least some information on how health care practitioners will apply to become providers under exchange health plans online. State optometric associations can provide additional information on exchanges for their members.

The marketplaces are scheduled to “go live” Oct. 1 of this year, but states will start announcing the health plans that are participating in the marketplaces this summer, according to the AOA Advocacy Group.

In most areas, health care practitioners will probably not be able to apply for status as panel providers until the plans are formally announced, although there will be many insurers already operating in the states where they will participate in the marketplace.

Practitioners should begin familiarizing themselves with their exchanges and may have to consider participation in a number of new health plans this fall.

They should also be prepared to assess participation in those plans from a practice management perspective, according to the AOA Third Party Center.

Optometrists generally desire to be providers for any insurance plans through which their patients might obtain coverage. However, they should also be prepared to assess plan reimbursement schedules, payment terms, and other provider contract provisions.

It is important that optometrists make wise business decisions when deciding whether to accept the terms of new provider agreements.

The AOA Third Party Center recently provided, through state optometric association executives, third-party chairs and coordinators, suggestions for assessing plans offered through health insurance exchanges.

AOA members can find additional information on health insurance marketplaces at http://tinyurl.com/clvdpst.

Health care reform resources available include the AOA’s “Frequently Asked Questions on the Essential Health Benefit and Insurance Marketplaces” (www.aoa.org/ Documents/FAQ_on_EHB.pdf) and the AOA “Health Insurance Marketplaces: What Optometrists Need to Know as Small Business Owners” fact sheets (www.aoa.org/ x25155.xml).

State health care exchanges by type

Federally facilitated exchanges
Alaska, Ala., Ariz., Fla., Ga., Ind., La., Kan., Maine, Miss., Mo., Mont., N.C., N.D., Neb., N.J., Ohio, Okla., Pa., S.C., S.D., Tenn., Texas, Va., Wis., Wyo.

Partnership exchanges
Ark., Del., Iowa, Ill., Mich., N.H., W.Va.

State-based exchanges
Calif., Colo., Conn., D.C., Hawaii, Idaho, Ky., Mass., Md., Minn., N.M. , Nev., N.Y., Ore., R.I., Utah, Vt., Wash.

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