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When Will We See Vision Coverage in the ACA’s Exchanges?

The Affordable Care Act was built on the promise of providing reasonably priced health insurance to the masses. In most states, vision care is not yet part of that package.

The ACA requires plans offered through the insurance exchanges to cover just pediatric eye care services and medical vision care, such as cataract surgery, for adults. As a result, plans don’t have to cover routine eye exams or corrective lenses for adults. Adults who have exchange-based health plans can purchase vision coverage separately, though they cannot use any subsidy money for stand-alone vision insurance sold outside the exchanges.

Vision insurers argue that regular eye care can help to detect early signs of chronic diseases and cure or prevent vision problems. But for vision care to be included under the law, Congress would have to amend the original legislation or all basic health plans would have to be required to cover eye care.

Why Vision Care Isn’t a Required Benefit

Those who argue against including vision coverage in regular medical plans often say that consumers can afford vision insurance on their own. They also maintain that vision care “doesn’t rise to the same level of importance as treating a heart condition” or other serious medical problems, Marge Ginsburg, executive director of the Center for Healthcare Decisions, told California Healthline.

“There was a little part of me that was surprised when the ACA didn’t include [vision coverage] as a part of its basic benefits,” Ginsburg said, given how inexpensive vision insurance can be. She added, “If Congress had asked me, I would have said yes [to including vision coverage in the exchanges] simply for the market value. It just would have made it a somewhat sweeter deal.”

However, Ginsburg said, “At the end of the day, [the government] had to find a package that was going to be the least expensive thing and yet the most comprehensive that they could afford.”

Vision Insurers’ Arguments for Inclusion

Vision insurers and eye care professionals argue that regular eye care is a vital component of preventive medicine — one of the core aims of the ACA. According to the American Optometric Association, several chronic health conditions can be identified during a routine eye exam, including:

  • Hypertension;
  • Inflammatory conditions;
  • Tumors; and
  • Undiagnosed strokes.

Richard Soden — a member of the AOA’s Third Party Center Executive Committee and vice president for clinical affairs at the State University of New York’s College of Optometry — noted that integrating vision care into health plans also could save insurers and consumers money in the long run. Soden said, “Health care costs will go down if we’re able to treat [conditions listed above] at an earlier stage.”

Further, adding in vision care to medical plans on the exchanges might make them more attractive, according to Jim McGrann, president of VSP, the largest vision insurer in the U.S. As of now, more than one-third of individuals enrolled in the insurer’s individual vision plans are under age 35 — a target age group of the ACA.

Ginsburg said, “The bottom line is yes, people really love having vision included and almost all of them want to include vision care,” adding, “Even a meager benefit … has meaning to people, even if they know that it’s not going to make a tremendous difference to them financially.”

Meanwhile, insurers — including those providing vision coverage — all pay the same ACA-related taxes, to the tune of $8 billion so far this year. VSP had to pay $25 million in such taxes by Sept. 30. But whereas medical insurers can compete on the exchanges, vision insurers like VSP say they have no place in most of the marketplaces.

How Some States Have Addressed the Issue

Some states — including Colorado, Hawaii and Nevada — already have taken action to allow vision insurance to be sold through their insurance exchanges. In Colorado, the Board of Directors of the state exchange voted early on to offer vision coverage through the marketplace in a variety of ways. The board agreed to build a technology system that would allow consumers shopping on the exchange to select:

  • Medical plans that include vision benefits; or
  • Stand-alone vision plans.  

However, a similar attempt in California was unsuccessful. State lawmakers passed legislation (AB 1877) that would have added vision coverage to the offerings on Covered California by creating a vision care access council. The council would have contracted with insurers to provide stand-alone vision plans. The council and its processes would have been modeled after the state’s health insurance exchange and would have sought to establish links to Covered California.

Despite bipartisan support for the measure, Gov. Jerry Brown (D) vetoed it in September. In his veto message, Brown wrote, “Creating a new state bureaucracy to inform consumers about vision plans isn’t necessary, nor is it advisable to divert Covered California’s focus with a new scheme, the governance of which may be impermissible under federal rules.”

What Could Tip the Scales for Vision Coverage

Rob Lynch, CEO of Rancho Cordova-based VSP, said that many officials are unsure who has the power to change the rules. Lynch said, “Everyone agrees that stand-alone vision plans should be included,” but “[e]verybody points to somebody else as being the responsible party to make that happen.”

While most state exchanges continue to exclude vision coverage from their offerings, AOA’s Third Party Center Executive Committee has noted that “more competition on exchanges could present more opportunities for optometrists to join new networks [in 2015], provided that [they] are credentialed with those networks.”

A shortage of primary care providers also could put more weight on the argument for routine eye exams as primary care. Stephen Montaquila, chair of the committee, said, “As the insurers build their offerings, they must have providers.”

In addition, AOA points out that new insurance entities or care models could emerge in 2015 that will increase consumers’ vision coverage options.

While a few states have taken advantage of an opportunity to offer their residents vision coverage through the exchanges, McGrann noted, “At the federal level, there continues to be a lack of clarity and confusion about whether vision is an essential service or not.”

That lack of clarity could be why state officials — like California’s governor — have hesitated to add vision insurance to their ACA marketplaces. And without further clarity, that hesitation is likely to continue.

Around the Nation

Financial impacts slowing. FierceHealthFinance highlights a recent Premier survey that found financial issues related to reimbursement cuts under the Affordable Care Act are beginning to recede.

Reform affecting diagnostic imaging market. DotMed Daily News reports that health care reform likely will have a negative effect on the diagnostic imaging market in the U.S.

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