Health and Vision Plans

The AOA Third Party Center advocates for the inclusion of full-scope optometric care and the inclusion of comprehensive ophthalmic examinations as a core benefit in all medical insurance and ERISA plans so that all Americans have access to quality eye care through their choice of appropriate provider.

Health and Vision Plans/Health Vision Action Plan Banner

  • With new laws enacted by Congress, more legislation anticipated this year at the federal and state level, an expectation of additional federal regulation, and a recent Supreme Court ruling affecting the reach of longstanding insurance law, the AOA’s Third Party Center seeks to use new and traditional paths to challenge undesirable policies and actions of health and vision plans. If you or your practice are experiencing difficulties with a health or vision plan, please report this to the Third Party Center at  stopplanabuses@aoa.org.
  • Come back to this page regularly to find out AOA / affiliate efforts in support of fair care coverage policies.
Plan Member Doctor Concern/Complaint Action Result
Aetna Medicare Aetna Medicare was denying claims stating a clinic was out of network AOA reported this issue to the plan Aetna reviewed the request and corrected the problem
BCBS Health AdvantagePayor is not covering CPT 67840 Payor is not covering eyelid lesion removal (CPT 67840) if it is performed by an OD, despite the fact it is allowed by scope of practice in Arkansas. Letter sent to BCBS Health Advantage Seeking prompt reply.  Will follow-up as needed to secure.
Humana Bundling refraction into eye exam billing, Humana directed eyemed to not reimburse for refraction only claims, and Humana is only allowing up to 100% of the Medicaid allowable when doctors prescribe medically necessary contact lenses We have sent a letter to Humana and requested a meeting to discuss the issues Seeking prompt reply.  Will follow-up as needed to secure.
Delta Dental Delta Dental mischaracterized the role of an optometrist in an article they published that aimed to differentiate between an ophthalmologist and optometrist Letter sent to Delta Dental on behalf of AOA, Wisconsin Optometric Association, and Illinois Optometric Association. Meeting requested with Delta Dental. We are scheduling a meeting to speak with Delta Dental. After we brought the issue of the blog post to their attention, they have updated their post to include AOA's definition of an OD.
Aetna Denial of two scleral lenses on the same day AOA reported this issue to the plan Company updated edits to allow for billing of two scleral lenses at same date of service. 
VSP Confusing guidance received regarding appropirate copayments to charge.  AOA engaged the plan to address this issue.  Payer reached out to member doctor to address directly. 
TRICARE Denied coverage for Oxervate eye drops AOA reached out to the company reporting our concern that an incorrect claims processing edit or a coverage policy exists that is denying medications prescribed by ODs for TRICARE patients Seeking prompt reply.  Will follow-up as needed to secure.
Harvard Pilgrim  Bundling refraction into eye exam billing AOA sent a letter to the company asking Harvard Pilgrim to review their policy that indicates that refraction will not be paid with an eye exam Plan seeking additional information from AOA on other insurers that cover refraction. 
Congress medicare pay cuts continue to cause challenges and patient access issues AOA is taking these concerns to congress. Doctors should visit the leg action center to make their voice heard: https://www.aoa.org/advocacy/federal/action-center?sso=y ongoing 
Congress Reintroduction of the Dental and Optometric Care (DOC) Access Act. Championed by both the AOA and American Dental Association, the bipartisan DOC Access Act complements state-level vision and dental plan laws by disallowing detrimental policies by ERISA and other federally regulated vision, dental and health plans. The DOC Access Act would prohibit plans from limiting patients’ and doctors’ choice of labs, as well as price-fixing noncovered services and materials. Bolstered by a second Avalon Health Economics report that concluded such mandates result in higher costs, less convenience and worse health outcomes, advocates found support late in the 117th Congress among a bipartisan coalition, including the Hispanic Leadership Fund and the Southern Christian Leadership Global Policy Initiative. The DOC Access Act remains a key priority for the AOA’s vision plan advocacy. Attend AOACH in June! 
CMS  Currently, some patients choose MA plans not realizing their long term OD is not credentialed with the plan.  AOA urges CMS to require agents to confirm whether a patients doctors are on the plan before selling the plan to the patient.  (4/10/23) CMS has finalized a new requirement for MA plan brokers to ask beneficiaries certain questions prior to enrollment, including confirming whether a beneficiary’s current or preferred providers or pharmacies are in-network.
CMS  Currently  Part D sponsors can immediately remove from the formulary a brand name drug and substitute its newly released generic equivalent.  AOA urges CMS to notify the prescribing physician when any change will occur in what is ultimately provided to the patient. (4/10/23)CMS finalized a rule that did not address its previously outlined proposals regarding new Part D plan formulary flexibility regarding immediate formulary substitutions for certain biological products and authorized generics. We will continue to have discussions with CMS to ensure this is addressed. 
CMS  PACE program patients are not required to have vision care included in their care plan which creates challenges for these patients.  Urge CMS to require that the PACE participant’s plan of care must address the participant’s vision needs.   (4/10/23) CMS finalized a proposal to add a list of 25 specialties that PACE organizations are required to contract with, but it did not include optometry. While PACE organizations may still contract with optometrists, they are not required to. We will continue conversations with CMS to ensure PACE organizations are required to contract with optometrists.
CMS  Prior authorization challenges in MA plans.  Outreach to CMS to require that all MA plans establish a Utilization Management Committee to review all utilization management, including prior authorization, policies annually and to ensure they are consistent with current, traditional Medicare's national and local coverage decisions and guidelines.  (4/10/23) CMS has finalized a proposal to require that all MA plans establish a Utilization Management Committee to review all utilization management, including prior authorization, policies annually and to ensure they are consistent with current, traditional Medicare's national and local coverage decisions and guidelines.
CMS Prior authorization challenges in MA plans.  Outreach to CMS to ensure MA plans cannot deny coverage of a Medicare covered item or service based on internal, proprietary, or external clinical criteria not found in Traditional Medicare coverage policies.  (4/10/23) CMS has finalized a proposal to preclude MA plans from denying coverage of a Medicare covered item or service based on internal, proprietary, or external clinical criteria not found in Traditional Medicare coverage policies. However, MA organizations may create publicly accessible internal coverage criteria that are based on current evidence in widely used treatment guidelines or clinical literature when coverage criteria are not fully established in applicable Medicare statute, regulation, NCD or LCD
Vpay Reports from providers on charges related to EFT VPay indicated they have some no cost options for doctors. AOA identified an additional product that does not have a no cost option.  Considering other state and legal action to ensure options for physicians. 
Michigan Medicaid Recieved reports of varying coverage and payment for doctors of optometry and ophthalmologists.  Joint AOA and MOA sent to MI Medcaid seeking meeting to address payment and coverage discrepencies.  Seeking prompt reply.  Will follow-up as needed to secure.
Virginia Medicaid Recived report that vision plan contract changed without sufficient notification.  Joint AOA and VOA letter sent to VA Medicaid urging greater transparency and communication.   Plan agreed to ensure state and national associations were given notice of changes.  
Surest concerned about the process Surest uses to implement tiered copayments letter sent to United CEO and Surest  Seeking prompt reply.  Will follow-up as needed to secure.
HealthLink HealthLink is charging providers an administration fee. Letter sent to Healthlink  Seeking prompt reply.  Will follow-up as needed to secure.
United Healthcare (Dual Complete) As a condition for participation in United Healthcare Dual Complete, ODs are required on enroll in March Vision (in violation of Louisiana law). Letter drafted to United CEO Brian Thompson. Meeting will be held to discuss challenges. 
Aetna Denying care provided in the home AOA outreach to Aetna Issue resolved following outreach
CMS  Using vision benefits to lure patients to plans that may not meet their needs AOA outreach to CMS to ensure that vision benefits are not marketed in areas where plans do not provide access to this critical care.   (4/10/23) CMS has finalized a requirement that prohibits the marketing of benefits in a service area where those benefits are not available, unless its avoidable due to the use of local/regional media.
Aetna Ongoing issues with down-coding program  AOA outreachto request meeting to address program concerns.  AOA is continuing a dialouge with Aetna on the program.  If you are part of the downcoding program and need asssistance please contact AOA.
Elevance Denial of dry eye testing because of provider type AOA outreach and meeting with plan Elevance reported they will correct their billing program
Nevada Medicaid Inapropriate bundling  AOA and NOA joint outreach to Nevada Medicaid Nevada Medicaid reported they would correct and update their provider manual to correct their previously inaccurate bundling policy

Payer Advocacy Goals

  1. The AOA is demanding that vision plans fix their inadequate valuation of the essential care we deliver. Reimbursement must fully reflect increased costs due to inflation and COVID-related protocols and mandates.
  2. The AOA is urging Federal officials to increase enforcement of national provider anti-discrimination laws, which specifically ban licensure-based restrictions on participation, coverage and reimbursement, including for biased ERISA plans.
  3. The AOA is insisting that health plans end the tying of vision plan credentialing and participation requirements. We are pushing these plans to better hold payers accountable by requiring that a significantly higher percentage of their resources are devoted to patient care, rather than profits.
  4. The AOA is spotlighting the scandalous failures of the Medicare Advantage plans that are misleading seniors and needlessly limiting their access to care. AOA is now pushing Congress to enact the Seniors Timely Access to Care Act to reform the broken prior authorization system to cut unnecessary care delays for patients and ease administrative burdens on doctors.
  5. The AOA is, through a united advocacy front with our American Dental Association partners, building support on Capitol Hill and in the Administration for legislation before Congress (the bipartisan and bicameral Dental and Optometric Care “DOC” Access Act) to outlaw documented plan abuses, including restrictions on lab choice and forced discounts. (Already, in 2020, through our work with the dentists and other provider groups, Congress successfully eliminated the McCarran-Ferguson anti-trust exemption that the insurance industry enjoyed for 75 years.)
  6. The AOA is championing the need for the Medicare reimbursement system to be revamped so that doctors are more fairly paid for the quality care they provide and aren’t required to jump through unnecessary hoops and push paper to avoid year-over-year reimbursement cuts.
  7. The AOA is partnering with affiliates in state legislatures nationwide to enact legislation, which allows doctors of optometry to best serve their patients eye health and vision care needs, by enabling critical statutory protections like lab choice and removing untenable contractual requirements.
  8. The AOA is actively engaged with national associations like the National Council of Insurance Legislators (NCOIL), working to defeat dangerous model legislative language proposed by the National Association of Vision Care Plans (NAVCP).

Have a third party question? Email TPC or call 703.837.1014.

Third Party Center Seeks Feedback on Health and Vision Plan Difficulties

With new laws enacted by Congress, more legislation anticipated this year at the federal and state level, an expectation of additional federal regulation, and a recent Supreme Court ruling affecting the reach of longstanding insurance law, the AOA’s Third Party Center (TPC) Executive Committee seeks to use new and traditional paths to challenge undesirable policies and actions of health and vision plans.

Clawbacks

Some vision plans are known to “claw back” payments from claims by recouping the funds from current claims. Many of these claims had been submitted a number of years in the past, and were often correctly billed. The AOA believes this violates many states’ insurance claim recoupment laws, which set limits on how long an insurer has to recoup money from overpaid claims (often 18 months or less). The AOA began collecting examples of these clawbacks in 2020 right before the start of the COVID-19 pandemic and will pick up this advocacy objective again in 2021. The AOA seeks to question this poor business practice, in coordination with state affiliates, in the states where these plans are most blatantly violating insurance recoupment laws.

If you have experienced a clawback from a vision plan for a years-old claim, please provide documentation (redacted to protect any confidential patient information) to the AOA’s Third Party Center at stopplanabuses@aoa.org.

Downcoding

Doctors of optometry, as well as other health care providers, have been impacted by health plan downcoding schemes where the plan automatically downcodes claims submitted for office visits or with certain modifiers for certain doctors who have been labeled by the plan for using some codes at greater frequency than peers, or greater than the plan believes is prudent.  It is based on an undisclosed algorithm, likely without a review of the doctor’s actual medical record and documentation, and impacted doctors are notified by letter. Doctors can appeal the downcoding decision, and if they are successful in enough appeals, they will be taken out of the program.

It is the AOA’s position that downcoding without reviewing the medical record is inappropriate and that third party payers should pay the claim or deny the claim based on the coverage and clinical needs of the patient, as documented in the medical record, and not make coverage decisions based merely on the identity of the doctor who submitted the claim. The AOA directly advocated on this issue prior to the pandemic and asked health and vision plans to cease these and other administrative hassles during the national health emergency but has heard that the practice is still occurring in many regions. AOA will continue to work on a resolution in 2021. If you are subject to a payer downcoding program and would like AOA guidance on appeals or coding, then email AOA’s Third Party Center at stopplanabuses@aoa.org.

Credentialing

Some health plans continue to steer doctors of optometry to credential with a vision plan instead of the health plan even though ophthalmologists may continue to contract directly with the health plan. In other situations, a doctor of optometry might be dropped from a medical plan network in favor of a network of optometrists rented from a vision plan.

If you have experienced this, then please send a report to stopplanabuses@aoa.org.

Combating Health and Vision Plan Anticompetitive Practices

While AOA regularly warns doctors not to engage in prohibited, anticompetitive conduct with competitors, the AOA is concerned that health and vision plans might have participated in anticompetitive practices that were exempt from federal oversight over the years. Recent changes in law have leveled the playing field. If you or your practice are experiencing anticompetitive behavior from a health or vision plan, please report this to the Third Party Center at stopplanabuses@aoa.org.

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