Managed Care

Providing Essential Pediatric Vision Benefits:


By ROB Editors
July 1, 2015

This newly published 2015 version of the“Navigation Guide to Health Care Reform for Independent Optometrists” was commissioned by Vision Source and produced by Review of Optometric Business. This comprehensivereport spotlights important trends in the fast-changing U.S.health care delivery system and underscores their meaning for independent optometrists. Included in the report are strategy imperatives and action plans to capture emerging opportunities. The followingexcerptis the first article in a four-part series.

CLICK HERE or on the image to the left to download the fullreport, published in April 2015.

Under the Affordable Care Act, beginning in January 2014, millions of children 18 years of age and younger became eligible, under their parents’ health insurance plans, for coverage of an annual eye exam and a vision device subsidy. The new pediatric vision benefit was enumerated as one of the 10 essential benefits required in all plans sold by state and federal insurance exchanges, as well as by non-grandfathered individual and small group plans. Optometrists who areaccredited by the insurers are able to be reimbursed for this care.
Research has shown that only 7 percent of children entering first grade had received an eye exam, and that undiagnosed vision problems among youth can lead to reduced academic performance. Analysis also indicated that simple screenings were insufficient to detect many vision issues.
Nearly 25 percent of the U.S. population, or 78 million people, are 18 years old or younger. AOA surveys suggest that less than 20 percent of OD patient visits are made by people in this age group. Most youths visit an eye doctor when they suspect or have been diagnosed with a vision problem. Thus, the new law has the potential to increase the number of youths who visit ODs, as well as the frequency of their visits. It’s likely that many parents remain unaware of the pediatric vision benefitoffered by their health insurer. A 2014 AOA survey indicated that two-thirds of adults did not know that the Affordable Care Act mandated pediatric vision coverage.

Action Plan

VIDEO: Jim Greenwood, president and CEO of Vision Source, explains how independent ODs can best serve patients and grow their practices in the new era of health care reform.

ASSESS COVERAGE. Determine the insurance companies covering patients in your area who are participating in the state exchange or offer pediatric vision
benefits.

DETERMINE BENEFITS. Determine the benefits and allowances offered by each plan. EDITOR’S NOTE: This is a phased process, in which an employer’s requirements are determined by number of employees. For more information see Resources at end of the this article.
EDUCATE PARENTS. Educate parents about the risks of undetected vision problems among children and about pediatric vision benefits.
• Develop a section on the practice web site explaining the importance of early detection of vision deficiencies and the availability of pediatric benefits.

• Develop a brochure about pediatric eyecare benefits and give to parents with children under 19.

• Conduct a mailing to parents during theback-to-school period encouraging youth exams.

• Issue press releases about pediatric care benefits.

INFORM PARENTS. Inform parents of any out-of-pocket costs involved in pediatric care.
• Different insurers may offer different reimbursements for pediatric care. These variables must be understood and relevant information communicated to patients.

• Materials subsidy may not cover full cost. A script should be developed encouraging purchase of higher performance eyewear offering safety and glare reduction benefits.

• Some health insurance plans may reimburse for pediatric vision services only after annual deductibles have been paid. Patients should be advised of the terms before service is provided.

BE CHILD-FRIENDLY. Make the practice child friendly.
• Dedicate space in the reception area for youth under 7 years of age and decorate to make children comfortable.

• Train staff to educate parents and youth about eyecare and make children feel welcome at the practice.
IMPLEMENT RECALL. Establish a recall program for pediatric patients.
• Schedule an annual exam for patients with refractive error or with vision problems.

ADDITIONAL RESOURCES

Essential Health Benefits, HealthCare.gov

Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage, Centers for Medicare & Medicaid Services

Essential Health Benefits Fact Sheet, Cigna

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