Feds Propose Health Care Reform’s Essential Health Benefits Cover Routine Eye Exams and Corrective Lenses

 WASHINGTON, D.C.—The Department of Health and Human Services (HHS) released a bulletin on Dec. 16 outlining proposed policies that will give states more flexibility and freedom to implement the Affordable Care Act, including how pediatric vision care would be provided as one of 10 “ essential health benefits.” According to the bulletin, HHS proposes that states should consider having pediatric vision care cover “routine eye examinations with refraction, corrective lenses and contact lenses.”

Under the intended approach announced by the HHS, states would have the flexibility to select an insurance plan that reflects the scope of services offered by a “typical employer plan” by using one of the following health insurance plans as a benchmark: one of the three largest small group plans in the state by enrollment, one of the three largest state employee health plans by enrollment, one of the three largest federal employee health plan options by enrollment, or the largest HMO plan offered in the state’s commercial market by enrollment. If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

“Not every benchmark plan includes coverage of all 10 categories of benefits identified [as essential health benefits],” according to the HHS bulletin, which added that among the most commonly non-covered categories of benefits among typical employer plans are pediatric vision services. To determine what pediatric vision services should be offered, HHS reviewed the Federal Employees Dental/Vision Insurance Program (FEDVIP). “The FEDVIP program is a stand-alone vision and dental program where eligible federal employees pay the full cost of their coverage,” states the bulletin. “The FEDVIP vision plan with the highest enrollment in 2010 covers routine eye examinations with refraction, corrective lenses and contact lenses. For pediatric vision services we intend to propose the plan must supplement with the benefits covered by the FEDVIP vision plan with the largest enrollment. The rationale for a different treatment of this category is that CHiP [the Children’s Healthcare Program] does not require vision services. We also seek comment on an approach that lets plans define the pediatric vision services with required reporting as a transition policy.”

Public comments are due by Jan. 31, 2012 and can be sent to EssentialHealthBenefits@cms.hhs.gov.

In its interpretation of the bulletin, the American Optometric Association announced, “HHS essentially acknowledged that ‘pediatric vision care’ in the new health care law is centered on a comprehensive eye examination, not a screening offered alone or as part of a ‘well child’ office visit.” However, the AOA “believes significant ongoing federal and state advocacy is necessary to ensure that ‘pediatric vision care’ will not be downgraded to less than a comprehensive eye examination for the millions of newly insured Americans under these plans starting in 2014.”

While the bulletin suggests that states use the FEDVIP as a model, and the FEDVIP does cover comprehensive eye exams and materials, the bulletin is currently only a proposal, and nothing is definite yet. According to the not-for-profit vision benefits provider, VSP Vision Care, Inc., “Within the new state-defined structure for essential health benefits, there is no guarantee that comprehensive eye exams will be included. This poses a great risk for the optometric profession if the medical plan is relied on solely for access to patients—especially if the benefit is defined as a screening.”

Melissa Warren, a spokesperson for VSP, told Vision Monday, “One of the things that is important for the optometric profession to realize is that in the bulletin it doesn’t guarantee a comprehensive eye exam. With benefits left to the states, it opens it up to how they will define that benefit.”

Al Schubert, vice president of managed care and health policy for VSP added, “We certainly hope and aggressively advocate that it be a comprehensive eye exam, but it’s just not absolute.”

In addition, VSP is pleased that the language HHS used in its bulletin included mention of standalone vision plans. “The use of the wording stand-alone vision plans and the fact that stand-alone vision plans are included in some of the benchmarks we see as positive signs,” Warren told Vision Monday. (See “ Debate Intensifies Over Standalone Vision Plans' Role in Health Care Reform.” 

Julian Roberts, executive director of the National Association of Vision Care Plans (NAVCP), told Vision Monday that while he is encouraged by parts of the HHS bulletin he agrees that there is still a need for further clarification. However, he added, “We see some aspects of this being very positive in that they have stated that to some degree the benchmark is the FEDVIP plan, which includes a comprehensive exam and materials.”

Katherine Cohen, vice president of governmental affairs for the American Academy of Ophthalmology interprets the HHS bulletin in more definite terms. She told Vision Monday, “We were certainly glad to see that it kind of settled once and for all that refractions and eyeglasses will be covered for kids.”

However, she did not expect the flexibility that HHS proposes for the states. “There was kind of a surprise in that they are giving so much flexibility to the states,” she said. Her concern is, “They only gave the states the FEDVIP with the largest national enrollment as an option, and we think that may not be the best model for children. That’s an insurance plan developed for workers. For children, we actually prefer an EPSDT [Early Periodic Screening, Diagnosis, and Treatment] Medicaid program as a ‘gold standard’ with screening and treatment and eyeglasses for children who need them, so we’d like states to have another option.”

What’s next? With public comments due to EssentialHealthBenefits@cms.hhs.gov by Jan. 31, 2012, the various organizations have determined their next steps.

The AOA has established a plan that includes advocating “collectively for appropriate benchmark benefits for pediatric vision care” and “continuing pressure on HHS to ensure that no state will be able to offer an inadequate pediatric vision benefit.” At the state level, the AOA plans “full engagement in state-level implementation of the new health care law and full delegations to the upcoming AOA Super Advocacy Meetings in Washington, D.C., April 1 to 3 (AOA Congressional Advocacy Conference and AOA State Government and Third Party National Conference).”

Roberts of the NAVCP told Vision Monday, “We will review a little closer, define our response in January and respond by Jan. 31.” After all the responses are in by the end of January, it’s up to HHS to issue its proposed regulations.