AOA provides model legislation to fight forced discounts

Momentum is building in states to prohibit health plans from forcing discounts on non-covered services. Now, AOA leaders are urging members to promote model legislation that would serve as a strong template for future state laws.

"Several states have passed this legislation in some form, and there are others who plan to move forward."

"Several states have passed this legislation in some form or another," said Deanna Alexander, O.D., chair of the AOA's State Government Relations Committee. "And we understand that there are quite a number of states next year who plan to move this forward."

Texas has such a law in place. Before the law took effect, most managed care plans were dictating discounts and capped fees on non-covered items, said Tommy Lucas, O.D., who practices in Killeen and serves as legislative chair of the Texas Optometric Association.

The discounts and capped fees helped attract more clients for the plan, but "it was being done so at the sole financial expense of the small business optometrist," Dr. Lucas said.

Texas is not alone on this issue. During a recent AOA webinar that attracted listeners in 38 states, speakers discussed an AOA-drafted model law—one that would issue a prohibition against plans requiring set fees for non-covered services and materials.

Members interested in learning what their state is doing on this issue should contact their state association, Dr. Alexander said.

Holes exist in current laws

The model legislation would offer clarity and fill holes found in existing state laws, Dr. Alexander said.

In addition to Texas, Maryland and Kentucky have mandates in place to stop these discounts. New York also has a law on the books that covers dentistry, but the hope is the law will eventually cover optometry as well, Dr. Alexander said.

However, some of these laws use language modeled after similar dentistry laws. Unlike optometry, where non-covered services can include both services and materials, dental care includes only services.

Issues remain, though. In Kentucky, some insurers are trying to make an artificial distinction between services and materials, said Matt Burchett, O.D., who practices in Lexington and serves on the AOA's State Government Relations Committee. Legislative leaders have made it clear in letters to the Kentucky Department of Insurance that optometric services do include materials.

The Kentucky law is currently under state review. "When the Department of Insurance comes back with a favorable ruling, saying that vision services include materials, then we'll be able to see a greater impact—when the law's enforced," Dr. Burchett said.

The AOA's model legislation aims to avoid these concerns up front. "You definitely want to make sure your language includes that so there aren't any missteps afterward," Dr. Alexander said.