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Full eye health coverage of children to be a top nationwide priority in 2014

July 30, 2013

A recent state-by-state analysis of health plans to be offered under the 2010 Affordable Care Act indicates that nearly all states will feature a pediatric vision care benefit based on an annual comprehensive eye exam provided by an eye doctor and is embedded with other benefits as part of the overall health insurance plan.

The AOA has made the recognition of early and periodic comprehensive eye exams for America’s children a top priority.

Throughout the multi-year legislative and regulatory battle over health care reform, the AOA successfully fought for inclusion of the new benefit within the law and to ensure that it is integrated within the health plan and based on an annual comprehensive eye exam with coverage for materials.

Now, in all 50 states and Washington, D.C., pediatric eye health coverage has been specifically recognized as essential and is to be based on an embedded comprehensive eye exam benefit, through age 18, offered by all health plans in the state-based health insurance marketplaces as well as certain new health plans to be sold outside of the state marketplaces.

In 48 states and Washington, D.C., pediatric eye health coverage includes an annual exam, at least through age 18, with Hawaii indicating that it will follow recommendations from the American Academy of Pediatrics, and Massachusetts signifying it will cover eye exams every two years. In Kentucky, the pediatric essential benefit extends to age 21.

The analysis also indicates that no restrictions exist that would prevent any of the roughly 8 million currently uninsured kids who will gain eye health coverage from directly accessing an optometrist for their eye health care.
Though adult eye exams may be covered in health plans offered through state marketplaces at no additional cost to consumers – and roughly 27 states have included an adult eye health benefit in their benchmark plans – it is unclear at this point how widespread this coverage may be as the state-based marketplaces come online.

In 48 states and the District of Columbia, pediatric eye health coverage includes materials.

In Massachusetts and Colorado, the plans reportedly do not cover materials. In Kansas, though, the benefit includes up to three sets of lenses and frames per year.

The analysis also indicates that vision therapy services can be covered. In the state of Washington, the habilitative portion of the essential health benefits package includes coverage for vision therapy.

In Kentucky, coverage for vision therapy is included within the pediatric vision care essential benefit.
The pediatric vision care essential benefit analysis was prepared by the AOA Washington office team in consultation with state associations.

For more information on the coordinated efforts of the AOA and state associations to shape the patient access and eye health provisions of the new health law, contact Jon Hymes, AOA Washington office director, at 800-365-2219 or jfhymes@aoa.org.

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