The ACA and Practical Applications

By Dr. DavDr. David Andersonid Anderson –  So, the Affordable Care Act is here – now what? I know we have all seen some impact from the changes brought by the ACA. Some were with our own insurance plans and unexpected. Some were with insurance that our patients have. Some changes will be from new patients who previously didn’t have health coverage. With all of this change, a few questions came to mind.

  • Where do I go to evaluate the exchange plans to find out whether I am a provider for these plans?
  • How do I find out the fee schedule for these new plans?
  • How do I know if I am a provider for the “new” plans that are subject to ACA minimum requirements to be a privately sold plan?
  • I understand there will be a new network with the potential for providers being left off plans (e.g. UHC and other skinny networks). How do I find out if I am included, or have been dropped from the network?
  • How do I find the fee schedules for these plans?
  • In my area, there are some newly developed Accountable Care Organizations (ACO’s) that are self-insured by a hospital group. How do I find out about these plans?
  • How do I know which medical plans cover children’s vision benefits, and which plans have subcontracted the services/materials to a vision plan?

The best place to find answers is with the specific carrier of these plans and their provider portal information. Health care providers should have been notified by mail of any changes at the end of last year. In most cases, if you are already a provider for Medical Mutual, Humana, Buckeye, CareSource, Molina or Paramount, then you are already a provider for those on the exchange as well, and the new ACA minimum-required plans.

Speak with your carrier representatives, and email them your questions. This gives you a permanent record. The reps can give you more specifics for their plans. Each company is free to provide these plans, within certain guidelines as laid out by the ACA, as they find most appropriate. The insurance companies will use existing fee schedules unless they have new signed agreements or amendments with you. In many cases, this means Medicaid levels of reimbursement. Additionally, each insurance company has a website that you can access for information. You can find out if you are a provider by searching for your own name on their “find a doctor” feature on each website.

The exchange plans sold in Ohio can be found on This website allows a search by county to find out about the new exchange plans and provider panels. Generally, you will have to request fee schedules by providing specific CPT codes. Admittedly, the website is set up for those people looking to purchase an insurance plan, but there is still information about the plans that our patients will be gaining access to.

Some information is not readily available at this time, such as how certain ACOs affect you and your patients. This is a new and rapidly changing area of health care. At this point, discussion with your patients and perhaps administrators at your local hospital group may be the best way to gather information about these plans.

When we review vision benefits, the ACA law requires each plan to provide a comprehensive examination and materials to children age 18 and under. Each insurance company has its own way of interpreting how this benefit is to be implemented. In some cases, the eye care product will be subcontracted to a vendor like VSP or EyeMed. In other cases, the plan will be managing the vision portion themselves. The websites are a good source for ACA-related product information. Continue watching this OOA Blog for further updates on this topic.

In summary, through all the confusion there is information available. Certainly, much more change will come. The best advice is to know the plans you are on, and contact those plans to ask about how they intend to comply with the children’s benefits.

Ask them if vision benefits will be subcontracted to another company. Ask them if there are new networks and if you are still on them. Decide which of these plans are most suited to your practice and your patients. Finally, be ready for a shift in both patient demand as well patient coverage for optical goods for some plans.

One final question: Is the ACA here to stay? Whether it is or not obviously will play out in the next year or two. We must work hard from all facets of healthcare reform to assure that primary eye care is a core component of every individual’s health care.

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