Small Business OD FAQ

Health Insurance “Marketplaces”:

What Optometrists Need to Know as Small Business Owners

The Affordable Care Act mandated the development of health insurance exchanges, also known as, marketplaces. A health insurance marketplace is a place where consumers and small business owners can go to purchase health care insurance.  Starting in 2014, these marketplaces will be accessible through a variety of means including the Internet, call centers, agents and brokers, in person, or by mail. There has been much discussion and misinformation circulated regarding the responsibilities of small business owners with regard to providing health insurance coverage to employees both inside and outside of the Health Insurance Marketplaces.  Many optometrists may be concerned about their role and responsibilities as small business owners. The frequently asked questions below provide the information you need to know now.

As an optometrist and a small business owner, where can I go to look at health insurance coverage options for my employees?

Beginning in 2014, Small Business Health Options Program (SHOP) Exchanges will be available to small business owners in each state. Through the SHOP exchanges, employers can review coverage options and provide their employees with qualified health plans (QHPs) to choose from for health insurance coverage.  Insurance options and information is also currently available at:

What sort of benefits will health plans offer in the SHOP Exchanges?

All small group and individual health plans will cover essential health benefits in the new exchange marketplaces or in the traditional open market that remains.  Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. The AOA successfully worked with Congress to ensure that pediatric vision coverage is considered an essential health benefit in all individual and small group plans, inside and outside the health insurance exchanges. For additional information see

How do I access the SHOP exchanges?

The SHOP exchanges are still under development. Each state has had the option of choosing to create a fully state-based exchange, develop an exchange working with the federal government or, if a state is not willing or able to develop an exchange, the federal government will develop and operate the exchange on behalf of the state.  For more information on the direction of your particular state visit: or 

I only employ three individuals in my optometric practice, am I eligible to purchase insurance through the SHOP Exchange?

Yes, businesses with up to 100 employees will be eligible.  However, until 2016 states may limit participation to businesses with only up to 50 employees. State departments of insurance can provide more information on participation thresholds.

I employ 10 full-time-equivalent (FTE) employees in my optometry practice.  Will I be forced to pay a penalty if I don’t offer those employees health insurance  coverage?

No.  Employers with fewer than 50 full time equivalent (FTE) employees will not incur any fines if the employer chooses not to offer health insurance coverage to employees.

I offer health insurance coverage to my employees now and I’d be interested in using the SHOP Exchanges in the future. When can I start?  

The open enrollment period for exchanges will begin on October 1, 2013.

If I currently use an insurance broker to help me purchase insurance for my employees, do I need to continue to use the broker when using the SHOP Exchange?

You are not required to use an insurance broker.  If you would like to continue to use a broker you may, but you are also able to purchase insurance independently.

If my employees choose different plans from the options available to them in the SHOP will I be required to make separate payments to all the different plans?

No. You will be able to make a single monthly payment to SHOP.

I don’t currently offer insurance to my employees but I would like to in the future if it is financially feasible.  What do I need to know?

The ACA includes some provisions to encourage small business owners to provide insurance coverage to employees.  If you have up to 25 employees, pay average annual wages below $50,000, and cover at least 50 percent of the cost of health insurance coverage, you may qualify for a small business tax credit of up to 35 percent.  This tax credit was included in the legislation in an attempt to offset the cost of insurance. The credit is supposed to increase to 50 percent in 2014.

The Department of Health and Human Services has also released some brief guidance regarding issues small business owners may wish to consider if using the SHOP Exchanges.  That information is available here:

As a small business owner am I forced to use the SHOP Exchanges?

No, although at least one jurisdiction has proposed it. In all or nearly all states, you will be able to decide whether or not you would like to participate in SHOP Exchanges. If you currently buy insurance from an insurance company, you can continue to do so.  It is important to note that the small business tax credit for offering insurance coverage is only available if you purchase insurance through the Exchange.

I don’t offer health coverage to my employees and I don’t plan to in the future.  Do my employees have any options for purchasing coverage?

Yes. Your employees and their families will be eligible to purchase insurance coverage through the Exchange.

How much will the penalty be to my practice if I don’t offer health insurance to my employees?

To reiterate, penalties will only be assessed for employers who have more than 50 full-time-equivalent (FTE) employees.  Those employers that meet the size requirement and do not offer health benefits coverage will be required to pay a fine of $2,000 per year for each full-time employee, excluding the first 30 full-time employees. Additionally, employers with more than 50 FTEs that do offer health benefits coverage but the coverage is considered unaffordable may be assessed a fine of $3,000 per year for each full-time employee receiving federal financial assistance.  This payment penalty cannot be greater than the penalty that would occur if the business did not offer health care coverage at all.

How is a full-time-equivalent (FTE) defined?

Full time is considered 30 or more hours per week.  FTEs are calculated by summing the hours of full and part-time employees. As such, two half-time employees are equivalent to one full-time employee.

I currently have over 50 full time employees but I am planning to downsize as I approach retirement.  When will it be determined whether I have 50 or more full time employees?

The U.S. Internal Revenue Service (IRS) has provided detailed guidance regarding when and how to determine the number of full time employees a business has:  In essence, employers can choose either a six- month or 12-month period in 2013 to  determine each employee’s full-time status. An employer would review the  six-month or 12-month period to determine whether the employee averaged at least 30 hours per week during the specified period which would make that employee a full time employee.

If I have more than 50 employees can I reclassify some of them as consultants to avoid the requirement to provide insurance coverage?

An employment attorney should be consulted for assistance in classifying individuals that you employ. It is also important to note that the IRS performs audits to determine whether individuals have been inappropriately classified as consultants.

How many businesses are expected to incur financial penalties for failing to provide adequate health care coverage?

The Department of Health and Human Services (HHS) estimates that fewer than two percent of large employers will be fined.

Additional Resources

AOA Guidance and Information for ODs:

General Information:

Tax Information:

Current Coverage Options:


Ohio Medicaid Statewide Plans

Ohio Medicaid statewide plans beginning July 1, 2013 will be CareSource, Buckeye, Molina, Paramount and United HealthCare.

Plans for the Medicare/Medicaid demonstration (duals) will be regional, not statewide, and are Aetna, CareSource, Buckeye, Molina, and United Healthcare.

AOA’s Top 5 ACA Changes Optometrists Must Get Ready For in 2014

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:

Dr. Walt West at Practice Management Institute

In addition to Dr. Chuck Brownlow’s Medical Records Compliance Workshop, Dr. Walt West will present two courses at Practice Management Institute in Columbus. Education for ODs and Allied Eye Professionals:

The Future of Independent Optometry and Change as a Strategic Advantage
. . . . Preparing For the Healthcare Affordability Act
(COPE applied for)
9:30 am – 11:30 am
Learn the key elements that allow you to turn the frustration of change into your strategic advantage. Discover the techniques that allow you to lead more effectively in a rapidly changing environment and understand the fundamentals that will best prepare you to embrace and leverage change. You will learn how to identify productive and non-productive change behaviors within your organization, and apply communication techniques that reduce conflict, improve understanding, and increase buy-in by your employees. By applying the principles presented you will be prepared to leverage change for a sustainable strategic advantage and better align the goals of your individual employees with your vision of success in practice.

Pulse Points of a Million Dollar Practice
1:30 pm – 3:30 pm
This course identifies 10 key areas where business owners can improve their individual performance and increase the size and success of their practice. Use these techniques to take your office to the next level.

Register online here. Download printable registration here.

Brownlow Compliance Workshop in Ohio

Brownlow Compliance Workshop in Ohio

Dr. Chuck Brownlow presented his Medical Records Compliance Workshop For Paper or Electronic Records in Columbus on February 6 to 50 ODs and staff. The workshop educated attendees on Medicare and other payer audits, the role of medical records in patient care, choosing visit and procedure codes, and creating a compliance manual for the office. Included was a complete review of five charts per doctor with a full report with grades, recommendations and suggested improvements.

Because of the intensity of the topic, attendance is limited to 50. Doctors are encouraged to attend with their billing staff person.

The workshop will be offered again in Ohio at Practice Management Institute on May 1 in Columbus and at the EastWest Eye Conference in October.

More info can be found here. Register online here. Download printable registration here.

Zone 11 Event – February 18

What: A Case Study in Addressing Your Presbyopic Patients’ Vision Correction Needs
Sponsored by: Alcon
Presented by: Dr. Roy Kline
When: February 18 @ 6:00 pm
Where: Final Cut, Hollywood Casino, 777 Hollywood Blvd., Toledo, OH 43605
RSVP by February 4 to Beth Samenuk – (567)686-2108 or

Future Zone 11 MeetingsMarch 26 – Allergan Meeting @ Mancy’s Italian Grill

Contact: Dr. Bill Kegerize: 419-885-3640

Zone 12 Restasis Meeting – March 20

Consortium of Research and Education Promotional Presentation of Restasis
Presented by: Brian Mathie, OD
When: March 20 @ 6:30 pm
Where: Smith & Wollensky, 4145 The Strand, Easton Town Center, Columbus, 43219
RSVP by March 13 to Allergan Representative Amy Gordon: (614)264-6440
or online:

Future Zone 12 Meetings:
March 5 – Residents’ Night @ J.Liu
April 16 – Student Night @ Fawcett Center
May 15 – CE event with Midwest Retina
June – Staff/Family Appreciation @ Columbus Clippers

CMS Releases Sunshine Act

by Dr. Beth Muckley, Ohio Optometric Association Trustee

Under the Physician Payments Sunshine Act, financial relationships that drug and device makers have with doctors must be disclosed.

The Rule, “finalizes the provisions that require manufacturers of drugs, devices, biologicals, and medical supplies covered by Medicare, Medicaid, or the Children’s Health Insurance Program to report payments or other transfers of value they make to physicians and teaching hospitals to CMS,” the statement explained. “CMS will post that data to a public website. The final rule also requires manufacturers and group purchasing organizations (GPOs) to disclose to CMS physician ownership or investment interests.”

More information:

An Evolving Health Reform Landscape – Part 2 of 4

by Mark A. Ridenour of the Ridenour Group, Consultant to the Ohio Optometric Association

Primary care practices are moving to a Medical Home model. The medical home aims to replace the current episodic sick care model with one that employs a team of health care providers, led by the physician, to engage the patient in an ongoing relationship toward optimizing personal health and coordinating all care.  Access is enhanced by open scheduling, expanded hours, and communication options other than face-to-face.  The most common term used is the Patient-Centered Medical Home (PCMH) which is accredited by NCQA and others.  Accreditation is a requirement for most insurers to enable enhanced reimbursement.

The transformation of Primary Care practices to PCMH has increased exponentially across the country with robust development where additional state and federal level support is present.  There are now nearly 200 accredited PCMHs across Ohio, for example, with others in the pipeline aided by state funds targeted to assist practices in making this transformation.  Ohio has been recognized as a leader in PCMH with the Cincinnati/Dayton region selected as one of seven in the country where Medicare, under the CMS Innovation Center’s  Comprehensive Primary Care Initiative (CPCi), is joining nine other payers in support of a four year pilot expected to yield $15M from Medicare for 75 practices over the next four years.  Another government initiated model, Health Homes, is a Medicaid version focused on mental health and those with multiple chronic conditions.

“An Evolving Health Reform Landscape” is a four-part series.