Debate Intensifies Over Stand-Alone Vision Plans' Role in Health Care Reform

By John Sailer
Senior Editor

WASHINGTON, DC – As new health care reforms are implemented nationally, the debate over how vision care insurance fits in is heating up again. At issue is the question of whether stand-alone vision care plans will be permitted to participate in the health insurance exchanges being established at the state level without selling/contracting through a major medical plan. Some optometrists believe this situation would put them on unequal footing with other health care professionals.

The controversy erupted again in late October, when comments on this issue were due to the U.S. Department of Health and Human Services (HHS), which has the final word. The American Optometric Association (AOA), the National Association of Vision Care Plans (NAVCP), Vision Service Plan (VSP) and some Congressional Democrats sent letters to HHS offering opinions both for and against including stand-alone vision plans in the state health insurance exchanges. That triggered a torrent of responses from the optical community, with proponents from both sides making their points via blogs, email newsletters, internet videos, and other means.

So far, HHS has not indicated when it will finalize the regulations regarding stand-alone vision plans and the state health insurance exchanges. "It's in the hands of HHS," Julian Roberts, executive vice president/executive director of the NAVCP told Vision Monday, "We're expecting to see revised regs or finals within 30 to 60 days but have not gotten a firm indication. We don't know if it will be a revision or an interim final."

A Brief History of the Exchanges

When the Patient Protection and Affordable Care Act (ACA) was signed into law in 2010 it mandated that states establish exchanges where individuals and businesses could compare and purchase health insurance policies.

Within the ACA, Essential Health Benefits were defined as a set of health care service categories that must be covered by certain plans starting in 2014. Included among these benefits are "pediatric services, including oral and vision care."

The current regulations governing these exchanges allow for stand-alone dental plans to provide the pediatric requirement, but stand-alone vision plans are excluded from selling directly in the exchanges. Instead, according to the current regulations, vision care plans may provide coverage by selling/contracting through a major medical plan.

According to a November 18, 2011 entry on As Eye See It, a blog written for managed vision care provider VSP by Daniel L. Mannen, OD, FAAO, "stand-alone vision plans were poised to be included as direct participants in the exchanges until eleventh-hour lobbying by the American Optometric Association (AOA) ultimately kept them out."

The Conflict Begins

Part of that lobbying consisted of a letter dated September 22, 2009, and signed by the AOA, along with the American Academy of Ophthalmology, that stated, in part, "Any expansion of stand-alone vision plans through health care reform would result in a continuation of non-responsive action and fractured and uncoordinated care. This would include barriers to access and the increased likelihood of needless disruption of the type of health care you and other leaders in Congress are determined to see provided to children."

A 2009 Vision Monday article referenced that letter in its continuing coverage of this longstanding battle (see " Managed Vision's Role in Health Reform Still Hot Topic" ), which stated, "The AOA ruffled feathers among vision-plan providers…when it collaborated with the American Academy of Ophthalmology…" The same article went on to reference a subsequent joint statement issued by the AOA and VSP on October 27, 2009 stating that "both organizations are committed to expanded access to eyecare" and quoted AOA's then president, Randy Brooks, OD, as saying, "We're not against stand-alone vision plans."

However, only two months later, the AOA resigned from its membership in the National Association of Vision Care Plans (NAVCP), citing the managed vision group's "lobbying campaign" to secure its members' place in health care reform as the reason. (See " AOA Resigns from NAVCP, Citing Managed Vision Group's Health-Care 'Lobbying Campaign," Vision Monday January 14, 2010.)

The Arguments Continue

The conflict continues today, with both sides making their cases for their constituents and arguing their positions before legislators and the HHS.

On September 28, 2011, the AOA sent a letter to the Centers for Medicare & Medicaid Services (CMS) in the HHS covering many aspects of the establishment of exchanges and qualified health plans. In the eight-page letter, the only reference to stand-alone plans stated, "In its wisdom, Congress decided to specifically allow stand-alone dental plans to also participate directly in the exchange. The law does not allow for any other type of stand-alone plan to be marketed in the exchanges. CMS should require stand-alone dental plans to meet all of the requirements for qualified health plans except for coverage of essential benefits other than oral health care. In addition, to prevent re-fracturing health care delivery into silos, CMS should not require essential oral health care benefits be priced separately."

A month later, the NAVCP, representing the opposing viewpoint, also wrote to CMS, specifically stating, "In an effort to ensure that individuals in the exchanges are not lacking access to the benefits of managed vision care, HHS should extend the current exception for stand-alone dental plans, as they relate to the definition of a qualified health plan, to stand-alone vision plans."

A similar letter supporting the inclusion of stand-alone vision plans was also sent to HHS in October by VSP, the country's largest managed vision care plan, stating, "VSP requests that the Secretary exercise the authority granted under ACA to provide that an exchange allow limited scope stand-alone vision plans to be offered in the exchange, in the same manner provided for stand-alone dental benefits."

Part of VSP's reasoning for permitting stand-alone vision plans in the exchanges stems from a 2008-2009 study conducted for the NAVCP that found that stand-alone vision plans deliver 84 percent of all vision care benefits in the United States and 87 percent of comprehensive vision coverage (See " NAVCP User Survey Indicates Consumers with Stand-Alone Vision Plans Get More Eye Exams," Vision Monday July 19, 2010 and " NAVCP Survey Shows Stand-Alone Plans Prompt More Eye Exams," Vision Monday August 16, 2010). Independent research also shows that individuals with stand-alone vision coverage are far more likely to obtain regular comprehensive eye exams, according to the letter from the VSP.

Also in support of including stand-alone vision care plans in the exchanges, nine Democratic members of Congress sent a letter dated October 28, 2011 to HHS Secretary Kathleen Sebelius urging her "to use the authority granted to you by the Affordable Care Act (ACA) to permit stand-alone vision plans to meet the 'pediatric vision care' component of the Essential Health Benefits Package (EHBP) offered both inside and outside of the health care insurance exchanges."

5 “Americans with Stand-Alone Vision Plans are Twice as Likely to Receive Eye Exams.”
Press release by the National Association of Vision Care Plans, July 13, 2010.

The Blogosphere Erupts

In response, the optical community exploded with internet posts, blogs, videos, and all forms of discussions both for and against including stand-alone vision plans in the exchanges.

Mike Cohen, OD, FAAO, summed it up in the " Early December 2011" edition of his OD2OD email newsletter, "It seems as if every other email and blog I've received this week has been about VSP and/or the AOA; with the core issue being the inclusion of stand-alone health plans in health care reform."

The current president of the NAVCP, Richard Sanchez, CEO/president of Advantica Eyecare, joined in the discussion, writing in the November 18, 2011 Advantica Blog, "When the health care reform activity was taking place in Congress, stand-alone dental plans were included in health insurance exchanges, yet stand-alone vision plans were not included. The reason for this was a lack of cooperation between the American Optometric Association and vision care plans. The American Optometric Association believes their participation would be better served by only working with qualified health plans that participate in health exchanges. I take serious exception to that position as I believe [that] the health care exchanges, qualified health plans and stand-alone vision plans should participate to provide the greatest access for Americans seeking coverage."

To further this argument, Sanchez told Vision Monday, "The membership of NAVCP is pretty much all the vision plan companies in the U.S. We do cover over 150 million Americans through our vision plans, and to not be included we think is a step backward in terms of access for people to enter the exchanges."

The AOA defended its position with a letter from its president Dori M. Carlson, OD, FAAO, to its members dated November 21, 2011 and a video on its YouTube channel: " AOA to White House and VSP: Our profession must be defined by optometry." In it, she said, "With regard to stand-alone vision plans, they absolutely can participate in the state health insurance exchanges now being created. They can do so by working with qualified health plans to assure the delivery of the full range of essential eye care services we provide our patients. But they want something more. They want a special loophole in the law that would allow them to continue to profit at the levels they have in the past while maintaining a barrier to segregate optometry from the mainstream of health care. That status quo is good for some insurance companies, but it's not good for optometrists or our patients. 'Standing alone' is in their best interests, but in the new world order it is clear it will no longer be good for optometry."

A Decision is Imminent

Publicly, the American Optometric Association and the American Academy of Ophthalmology have argued against permitting stand-alone vision plans to participate in the exchanges (although the AOA now qualifies that stating that "they can do so by working with qualified health plans"), while the NAVCP, its members, including Advantica and VSP, and nine house Democrats as well, have all shown support for including stand-alone vision plans in the exchanges. Ultimately, the outcome will impact the entire eyecare community.

Both sides have made their points, but the debate continues. Now, HHS is in the process of finalizing the regulations related to whether or not stand-alone vision care plans will be allowed to participate in the state exchanges. The final decision now rests in the hands of the United States Department of Health and Human Services and its Secretary Kathleen Sebelius.

Pat McNeil, director of global integrated communications at VSP said an answer may come "sometime in the first three months of 2012."