Stand-Alone Plans: The Battle Is Now Waged at the State Level


Soon after it was determined that pediatric vision care would be among the 10 essential health benefits required for coverage by the Affordable Care Act, a controversy began over whether stand-alone vision plans would be permitted to participate in the state health insurance exchanges without partnering with a major medical plan.

When the ACA was signed into law, stand-alone vision plans were excluded from selling directly in the exchanges. Instead, vision care plans could provide coverage by contracting through a major medical plan.

A battle ensued with the main combatants being those representing stand-alone vision plans in support of their participation and the American Optometric Association against it. After the U.S. Department of Health and Human Services first decided to allow each state to decide how to handle stand-alone vision plans, organizations on both sides took their lobbying efforts to the state level.

A number of state optometric associations passed resolutions supporting the inclusion of stand-alone vision plans, including Arizona, California, Hawaii, Maryland and the District of Columbia. Others came out against permitting the direct participation of stand-alone vision plans. For example, Washington state insurance commissioner Mike Kriedler, OD, MPH, FAAO released a statement in February 2012 opposing the inclusion of stand-alone vision plans.

Ultimately, the argument became moot on March 29, 2013, when the Centers for Medicare & Medicaid Services issued a memo on “Frequently Asked Questions on Reuse of Exchange for Ancillary Products.” In the FAQ memo, federal guidelines indicated that while exchanges could provide education about ancillary benefits such as vision coverage and a link for purchasing them within an exchange’s infrastructure, the actual transaction could not be completed within the exchange itself, and federal subsidies could not be used for the sale of non-essential benefits.

Effectively, CMS disallowed stand-alone vision plans from directly participating in the state exchanges but permitted their sale, if a state desired, via a link for purchasing them outside of the exchanges. For example, the Connect for Health Colorado exchange provides a link for consumers to access stand-alone vision plans after they have completed their health insurance enrollment process.

Jim McGrann, president of VSP Vision Care, told Vision Monday that Hawaii and Nevada are also developing ways to sell stand-alone vision insurance “adjacent” to the exchanges rather than on them. Both approaches are expected to be similar to Colorado’s, according to a VSP spokesperson.

“There are three managed vision care plans on the Colorado exchange. Click the link for any of those three and go to their website to sign up for adult vision, but the transaction takes place outside the exchange,” said Julian Roberts, executive director of the National Association for Vision Care Plans. “There’s some discussion that Hawaii is moving forward with something similar, and Nevada is looking at doing an advertisement for vision on their exchange.”

That doesn’t mean, however, that VSP and other managed vision care providers are left out of most other state exchanges which are not pursuing this tactic. In those cases, they’re simply required to partner with a qualified health plan being sold through the exchanges. In the case of VSP, for example, this year the company added 85 health plan partnerships. Of those, 60 were established to provide pediatric essential health benefits coverage in conjunction with medical plans on the exchanges in 25 different states. For these 60 partnerships, VSP provides the Elements Plan, which is based on the federal guidelines required for pediatric vision care as an essential health benefit. ■