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How and Why to Get Behind Health Exchanges

It took more than two decades for optometrists to achieve drug prescribing rights. Now, ODs face another challenge: not getting shut out of Obamacare.
By Cheryl Murphy, OD, Contributing Editor

2/15/2013

Providing the highest possible quality eye care to our patients has been something optometrists have always found to be worth fighting for. After an uphill battle fought and waged by ODs nationwide for almost 17 years, each state in the US obtained DPA privileges, beginning with Rhode Island in 1971 and ending with Maryland in 1989. TPA rights took even longer—22 years.

Right now, for instance, optometrists in Florida are seeking prescriptive authority for oral medications. This reminds us that we are a legislated profession; we have to earn our privileges through legislation. Likewise, legislation supported by our opponents could potentially revoke those privileges—privileges that we perhaps take for granted.

Automatic Privileges?
Considering the decades’ long struggle to gain DPA and TPA rights, it is amazing to think that since 1998, optometry students in the US graduate with DPA and TPA rights automatically. Yet, for some optometrists outside of the 50 states, the fight for prescriptive privileges is still being waged.

Puerto Rico. In summer 2012, optometrists in Puerto Rico tried to obtain the right to deliver the level and quality of care matching that of other US ODs who have TPA rights. But once again, the bill was defeated—it was the seventh attempt in 15 years to pass such a bill. ODs in Puerto Rico may have lost this round, but vow to continue to fight for TPA rights.

Virgin Islands. In July 2012, the US Virgin Islands joined all 50 states to become the latest jurisdiction to acquire therapeutic privileges. But it wasn’t easy. They suffered strong opposition from both local ophthalmologists and others nationwide. But, the persistence of the Virgin Island ODs paid off. The bill was passed on July 18.

The Fight Has Just Begun
Maintaining and expanding the scope of optometry in the US requires continued support, persistence and a drive forward. Ensuring that each and every person in the United States is able to receive high quality eye care is our next fight, and it’s already being waged.

What Exactly is a Health Insurance Exchange?

“A health insurance exchange is an online marketplace targeted toward the individual market and those who work in a company of less than 100 employees who do not currently have insurance coverage or sufficient insurance coverage to purchase health insurance,” says Brian Reuwer, associate director of Advocacy and Affiliate Outreach for the American Optometric Association.

“The idea is that these two groups [the individual market and small group market], who are among the highest percentage of uninsured individuals, would be able to purchase reasonably affordable insurance if they were put into large insurance pools and given tax subsides,” Mr. Reuwer says.

These two exchanges—the exchange for individuals and the Small Business Health Options Program (SHOP) exchange—are technically separate but each state will have the choice to keep them separate or to combine them together and run them as one exchange (which is what most states are doing).

Mr. Reuwer adds, “The exchange can be run in one of three ways: by the state, as a partnership between the federal government and a state, or as a federally-facilitated exchange.” Exchanges must be operational by January 1, 2014.

Following the approval of President Obama’s Patient Protection and Affordable Care Act of 2010 (PPACA), essential health benefits packages and health insurance exchanges are now being set up in order to ensure that each individual will be able to get the health care they need.
Optometrists want and need to be included on the provider panels for these newly insured individuals. (See “What Exactly is a Health Insurance Exchange?”) Currently, 18 states have been conditionally approved to operate state-based health insurance exchanges, and two states have been conditionally approved to operate state partnership exchanges.

It’s important for optometrists to understand that “this is a new insurance marketplace for those who do not currently have insurance, so these are new patients and nobody who currently has insurance will lose it,” says the AOA’s Brian Reuwer. “This also means that the health plans sold in the exchange will be subject to state insurance laws that prohibit discriminatory behavior by insurance companies, including the prohibitions under the Harkin Amendment—the first-of-its-kind federal nondiscrimination law that applies to health plans inside and outside of the exchange.”

The Harkin Amendment was the landmark provision that “bars health insurers from discriminating in plan coverage and participation against ODs and other providers,” according to the AOA.

This means that once ODs are included on the medical panel, they should not be discriminated against because of the type of license they have. It also means that newly insured patients will have access to ODs when they buy their insurance through the health insurance exchange. The Harkin Amendment, which is part of the PPACA, is set to go into effect in 2014.

The plans that participate in each state’s health insurance exchange are required to include certain health care benefits. These mandatory benefits are referred to as an essential health benefits package. (See “What is the Essential Health Benefits Package?”)

For eye doctors, one of the most important categories in the essential health benefits package is the inclusion of the pediatric vision benefit.

“A specific pediatric vision benefit has not necessarily been standard in commercial health plans,” says Mr. Reuwer. “So, in order to help states create a definition of the pediatric vision benefit, HHS said they could supplement the benefit with the largest Federal Employees Dental and Vision Insurance Program (FEDVIP) or the Children’s Health Insurance Program (CHIP). The largest FEDVIP plan [includes] a yearly comprehensive eye examination with a materials benefit for glasses or contacts.”

In addition, he says, “other medical eye services are included in another category—generally ambulatory patient services—but optometrists’ services could be covered in other categories, as well.” 

While an adult eye exam is not considered an essential benefit, some of the plans include the exam as part of its benchmark, says Mr. Reuwer. “In states where it is not included, there may be an opportunity for the local affiliates to add that to the plan,” he says.

Show ’Em Your Stuff
This is where optometrists come in. Health plans will need to ensure there are a sufficient number of providers on the health panels to provide the pediatric vision benefit.

What is the Essential Health Benefits Package?

Health plans that participate in each state’s health insurance exchange are required to include 10 essential health care benefits. Among these benefits are ambulatory patient services, emergency services, hospitalization, maternity/newborn care, mental health/substance abuse services, prescription drugs, laboratory services and more.

One of those mandatory benefits: pediatric services, including vision and dental care.

“The federal government recently issued a proposed rule that allowed a state to choose a benchmark health plan to base the essential health benefit (EHB) package for a transition period of two years. Afterwards, the federal government may develop another process for determining the essential health benefit package,” Mr. Reuwer says.

EHBs are all set for 2014 and 2015, he adds. “Each state was given the opportunity to choose a commercial health plan that would be the basis for the EHB. If they did not, then the federal government would choose a plan for them.”
“While the law does not specify which professionals patients must see to receive their new benefits, because the majority of the services will be primary eye care in nature, the bulk of the patients will be getting their eye care through optometrists,” says Mr. Reuwer.

He adds that, “while this does mean that insurance companies will have a lot of influence on the health care system, current state law, the Harkin Amendment and strong advocacy by the profession will help optometrists work towards fair and equitable treatment with a health plan.” 

Optometrists, along with the AOA, will work with state affiliates to make certain that those plans “are opening their networks and including optometrists—not just ophthalmologists—to ensure the newly insured are getting access to high quality eye care,” Mr. Reuwer says.

This is where US optometrists should focus our efforts. In addition to showing global support for full-scope optometric rights and privileges, we have to be sure that optometrists are front and center in the medical arena. We need to show other health care professionals and those in government that we are competent, ready and willing to do our part to provide each and every person with the quality eye care that they deserve and need.

How exactly do we do that? Optometrists around the country need to start monitoring health plans that are applying to sell in the exchanges; when the opportunity arises, and if it is a smart business decision for your practice, try to sign up for these health plans.

“With the influx of the newly insured and children across the country getting access to a strong vision and materials benefit, there will be opportunities for optometrists to see these newly-insured patients,” Mr. Reuwer says.

Also, “because the new coverage will be embedded in health plans and access to these patients will be through the health plans, it’s more important than ever for optometrists to be vigilant and to report to their state affiliates and the AOA if there is any discriminatory activity by health plans, so that it can be dealt with,” he adds. “The PPACA and current state law, including the Harkin Amendment, gives organized optometry some very powerful tools to combat discriminatory behavior by health plans. So, we must ensure that patients continue to have access to high quality services—and that we continue to fight to keep it that way.”



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