Top 5 ACA changes for 2014: Are you ready?
Next year will be a big year for health care reform. In 2014, many key parts of the Affordable Care Act (ACA) will go into effect. Below are the top 5 ACA changes for 2014—and how each one will affect your practice.
1. Health exchanges for insurance
These are new plans and newly insured people, so you should not lose patients because of the exchange. In fact, you should get new ones.
Health Insurance Marketplaces (aka Health Benefit Exchanges, Connectors, Exchanges, or HIX) will be implemented on Jan. 1, 2014. An exchange market will sell health plans primarily to people who do not have insurance. The goal is to create a new market for these individuals and small employers of up to 50 or 100 employees, which traditionally have high rates of uninsured people. They will also get tax breaks to help them afford health insurance. If they forgo insurance, they will have to pay a tax penalty ($95 in the first year or 1 percent of income).
What does this mean for ODs? These are new plans and newly insured people, so you should not lose patients because of the exchange. In fact, you should get new ones. If the plans 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 (see No. 2 below); optometrists will be needed on the panels to serve this population and 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 care essential health benefit
The pediatric vision benefit is one of the 10 essential benefits that create a basic benefits 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—which fought back against insurance companies and ophthalmology, which pushed for a weak benefit—this benefit will be a yearly eye exam with a materials benefit for every patient under 19. What does this mean for ODs? Potentially millions of new patients will have coverage that they didn't have before. You may want to start advertising to these potential patients and educating their parents about the services that optometrists provide and the need for pediatric eye exams.
3. Medicaid expansion
Starting in 2014, many states will expand their Medicaid program to everyone who is under 133 percent of the federal poverty line. Mainly, this will expand coverage to childless adults who generally are not covered in the Medicaid program. States can opt into this expansion or not. It 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. There is no deadline for adopting it, but 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 these patients. However, while states will get more money for covering this population, that will not necessarily translate into increased payments for providers. States will still face the same funding issues for the program, which could lead to an increase in Medicaid Managed Care plans in states. If 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, care coordination, care transition, and managed care—these are just some of the many ideas and acronyms being thrown around as ways to control the rising cost of health care. Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMH), for example, are two major cost-containment initiatives being tested. 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 such as diabetes. What does this mean for ODs? These new delivery models are not necessarily closed systems; you may be participating in one and not even realize it. Organizations that qualify as an ACO or PCMH may refer patients for diabetes-monitoring eye exams to meet certain quality measures. To be an integrated partner in an ACO or PCMH, providers must show value and savings to the ACO or PCMH. The AOA is working on materials to help optometrists demonstrate value, but you will need a full-scope optometry practice and a robust medical practice.
5. Changes that affect small business owners
Optometrists will face many of the same health care changes as other small business owners. For example, the coming exchanges may affect not only the patients you treat but also the people you employ. Visit our FAQ designed for small business owners—and be ready for coming changes.