We all know that the Affordable Care Act (ACA) implementation has been a major topic of concern in optometry and health care in general and the AOA and OOA have been working hard to keep you informed. 2014 is a major year in the implementation of the ACA and a lot of people are throwing around a lot of terms but what does the average optometrist need to know going into this very critical year?
Here is a list of the top 5 changes you need to know about going into 2014:
1. Health Insurance Marketplaces (also known as Health Benefit Exchanges, Connectors, Exchanges or HIX):
An exchange is a market place for selling health plans primarily to people who previously do not have insurance. The exchange market is for individuals and small employers up to 50 or 100 employees (depends on the state but most will be 50 at the start). These are groups that have traditionally high rates of noninsured and the idea is by creating a new market and giving them tax breaks that this population should be able to afford health insurance or pay a tax penalty ($95 in the first year or 1% of income).
What does this mean for ODs? These are new plans and newly insured people that will need health care so you should not lose patients because of the exchange, in fact you should be getting new ones. If the plans that eventually sell in the exchange make good business sense for your practice, you should sign up. Health plans in the exchange will have an integrated pediatric vision benefit (described below) so there will be a need for optometrists on the panels to service this population as well as to provide medical eye care to the newly insured. Finally, your state’s access and nondiscrimination laws will apply to these plans as will the Harkin Amendment, the first of its kind federal nondiscrimination language.
2. The Pediatric Vision Benefit:
The pediatric vision benefit is one of the 10 essential benefits spelled out by the ACA that create a basic benefit package for all health plans sold in the exchange and some plans outside of the exchange. Thanks to the advocacy of the AOA and state affiliates who fought back against insurance companies and ophthalmology who pushed for a weak benefit, this will be a yearly eye exam with a materials benefit for every patient under 19.
What does this mean for ODs? This means potentially millions of new patients nationwide that will have coverage that they didn’t have before. Optometrists may want to start advertising to these potential patients and educate the parents about the services that optometrists provide and the need for pediatric eye exams.
3. The Medicaid Expansion:
Starting in 2014, many states will expand their Medicaid program to everyone who is under 133% of the federal poverty line. Mainly, this will expand coverage to childless adults who generally are not covered in the Medicaid program. Due to last year’s Supreme Court ruling, states have an option if they want to take this expansion or not which will be fully funded by the federal government for at least three years. States will be getting a lot of pressure from hospitals to adopt the Medicaid expansion this year and while there is no deadline for adopting the option, the list of states taking the expansion is expected to fluctuate all year.
What does this mean for ODs? Optometrists who see Medicaid patients will see a significant increase in Medicaid patients starting in 2014. While states will get more money for covering these populations that will not necessarily translate into increased payments for providers and states will still face the same funding issues for the program as before which could turn to an increase in Medicaid Managed Care plans in states. Optometrists are one of the highest participating specialists in the Medicaid program and your services are highly valued by beneficiaries but not necessarily the state. If your Medicaid payments are too low in your state, contact your local affiliate and fight to ensure greater access to this vulnerable population.
4. New Payment Methods :
ACOs, PCMHs, episodic payment, bundled payment, integrated healthcare delivery, care coordination, care transition, and managed care are just some of the many terms being thrown around as ideas on how to control the rising cost of health care and while many of these ideas aren’t necessarily just being implemented in 2014, the increase of American’s with insurance coverage will place an increasing emphasis on controlling health care costs. Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMH), for example, are two major initiatives undertaken by the federal government and several payers to see if they are successful in holding down the costs of healthcare delivery. An ACO would save money by allowing providers to share in any cost savings achieved through better management of a patient’s care. PCMHs pay primary care providers extra to better manage a patient’s care, usually for chronic diseases like diabetes.
What does this mean for ODs? These new delivery models are not necessarily closed systems, and there may be a chance you are participating in one and not even realize it. Organizations that qualify as an ACO or PCMH may refer patients out for eye exams to monitor diabetes in order to meet certain quality measures. To truly be an integrated partner in an ACO or PCMH, providers must show value to the ACO or PCMH and demonstrate that being a member of the organization will help save money. The AOA is working on materials to help optometrists demonstrate value, but it will require that optometrists practice full scope optometry and have a very robust medical practice. Please read AOA publications for further details.
5. What Optometrists Need to Know as Small Business Owners:
As small business owners, optometrists will face many of the changes that other small business owners will face. The AOA has developed a Frequently Asked Question (FAQ) document to address many of these concerns. You can access the FAQ by going to the Health Care Reform page of the AOA website or by going to the following address: http://www.aoa.org/x25155.xml