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Health insurance marketplaces scheduled to open Oct. 1

September 3, 2013

Many optometrists across the nation are now receiving solicitations from insurance companies regarding participation in exchange-based health plans with an embedded pediatric vision essential health benefit as mandated by the Affordable Care Act (ACA).

As with all insurance programs, practitioners should thoroughly review provider participation agreements for the new plans, assessing the contract terms carefully, according to the AOA Third Party Center. For assistance, contact tpc@aoa.org.

The insurers offering plans through the new marketplaces will generally be well-established companies such as Blue Cross/Blue Shield, Aetna, or UnitedHealth.

“It will be up to those insurance companies to determine if they will use their existing provider networks for the new plans they offer through health insurance exchanges or if they will establish distinct new provider networks for their exchange-based plans. In some cases, insurance companies may issue separate contracts to health care practitioners for their new exchange-based plans, some of which will likely include lower reimbursement rates,” said Stephen Montaquila, O.D., chair of the AOA Third Party Center Executive Committee.

Offers to become participating providers in exchange-based plans will come from insurance companies, not the management of the exchanges.

“Many health care practitioners are under the impression that the exchanges are new payers providing insurance and contracting with doctors,” Dr. Montaquila said. “The exchanges have little, if anything, to do with provider contracting.”

Through the exchanges, private insurance carriers will offer plans meeting specified criteria. Uninsured people will be able to log onto exchange websites, modeled after travel sites such as Travelocity or Expedia, review the plans offered by the various insurance companies and then purchase a policy online. Many exchanges will offer 800 telephone lines and “walk-in” offices as well.

Of the 51 health insurance marketplaces being developed across the U.S., 17 will be state-based exchanges, 27 will federally facilitated exchanges, and seven will be “partnership” exchanges, developed jointly by state and federal government.

Specifics on the federally facilitated exchanges had not been announced at press time. 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 (http://tinyurl.com/insurancemarketplace). The HHS also offers a state-by-state health insurance exchange locator (www.healthcare.gov/marketplace/individual).

Optometrists can visit the websites to find contact information, organizational structure for the exchanges, and some information on how to apply to become providers. State optometric associations may provide additional information on exchanges for their members.

Multi-state plans will be available in 31 states in 2014 and in all states by 2017. Multi-state plans were created through the ACA to address the lack of competition in the individual health insurance market. Multi-state plans will be operated by the federal Office of Personnel Management, which is the entity that runs health insurance programs for Congress and federal employees. All multi-state plans must cover the same pediatric vision services for children.

AOA members can access a number of resources, including answers to frequently asked questions, to help explain the new insurance marketplaces and assess participation in these plans at http://tinyurl.com/AOAhealthreform.

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