Health insurance plans

When contracting with health care payers, doctors of optometry should be familiar with the laws surrounding health insurance plans.

Many doctors of optometry contract with multiple health care payers and find it useful to know which companies are the biggest players in their state. Below is a list of the top health payers nationally.

America’s top health payers (by covered lives)

Name

Total lives

Commercial

Government plans

Public employers

1 United Healthcare 44,996,566 27,833,999 11,279,965 37,602
2 Anthem (BCBS) 31,019,510 24,035,964 6,983,546 0
3 Aetna 21,950,474 17,609,065 3,793,720 120,761
4 Cigna 16,178,657 14,118,936 483,721 0
5 HCSC (BCBS) 15,554,420 14,754,728 799,692 0
6 Humana 12,589,899 1,444,202 4,964,793 6,180,904

Health insurance plans

Addressing Down-Coding Program

The American Optometric Association (AOA) opposes automatic downcoding programs that systematically downcode reported codes without records review. AOA has engaged directly with insurance companies who utilize these systems to raise our concerns on behalf of the profession of optometry and on behalf of the patients doctors serve.

If you are included in a downcoding program based on your claims reporting history, please notify the AOA at stopplanabuses@aoa.org

As we continue to advocate to change these programs, practices must appeal downcoded claims to be removed from the downcoding program.

If a high percentage of ALL downcoded claims are overturned, doctors are typically removed from the program.

Please report results of your appeals to AOA at the email above.

By following these links, you will find a template appeal letter and an example of strong documentation to support the level of care provided. Strong documentation is critical to successful appeals.

Nondiscrimination—Harkin Law

§ 2706(a) of the Public Health Service Act, created by § 1201 of Patient Protection and Affordable Care Act ("PPACA") states: "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures." 42 U.S.C. §300gg-5(a).

To what plans does it apply?

"Group health plans" and "health insurance issuers" offering group or individual health insurance coverage:

  • Self-insured employee health benefit plans.
  • Group health insurance (small group and large group employer plans).
  • Individual health insurance.

The ACA also amended ERISA to apply these requirements to ERISA plans, including self-insured plans.

To what plans does it not apply?

Does not include Medicare, Medicare Advantage, Medicare Supplement or Medicaid managed care plans. Most of those plans are already prohibited from discriminating, in terms of participation, reimbursement or indemnification, against any health care professional who is acting within the scope of his or her license or certification under state law, solely on the basis of the license or certification. Download the AOA Health Polity Institute fact sheet on Medicare Advantage and Physician Nondiscrimination.  

What does Harkin actually prohibit?

Bars discrimination with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law.

  • Ban on discrimination regarding "participation" relates to provider network participation.
  • Ban regarding "coverage" reaches terms of health plan coverage and plan design, such as services covered, benefit limits and enrollee cost-sharing.
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