AOA to CMS: Hold Medicare Advantage plans accountable

With a potentially hefty revenue increase for Medicare Advantage (MA) plans looming in 2023, the AOA is calling on the Centers for Medicare & Medicaid Services (CMS) to ensure that plans are held accountable for improved patient benefits and care, and that it put an end to discrimination against doctors of optometry when it comes to participation in the plans.

In a March 2 letter to Meena Seshamani, M.D., Ph.D., director, Center for Medicare, the AOA affirms the CMS for its instruction to MA plans to advance health equity, offering benefits that address critical care gaps and barriers to care, and a recommendation to MA plans to focus on equitable delivery of preventive and medical benefits.

However, the AOA expressed its concern that more could be done on the MA accountability front.

“While physician fee schedules in the fee for service program remain stagnant, we believe that any increase in Medicare Part C should truly be earned with exceptional patient satisfaction with the care delivered in this model and demonstrated savings in compiled value metrics,” AOA President Robert C. Layman, O.D., says in the letter. “We believe that it will be critical to ensure that plans are adhering to the statutory requirements to use at least 85% of their revenue for patient care and quality improvements, and to ensure that any administrative costs, including profits and salaries, do not exceed 15% of their revenue.

“It is also imperative that any additional government funding must be used to directly improve benefits and care,” Dr. Layman adds.

Patients missing out on care

Patients’ MA plans are required to cover necessary care related to eye diseases. Currently, that translates into plans providing coverage for an annual preventive eye examination, which may be administered through a subcontracted vision plan.

“However, while supplemental benefits are intended to be an added value for patients, our member doctors report that the subcontracting of a very limited subset of the care, often to a limited provider network, causes patient confusion,” Dr. Layman says. “They further report that because of this confusion, patients will come to the participating vision plan network doctor for their annual eye exam and forgo any follow-up care that may be necessary related to eye disease that had been identified and managed by other providers unrelated to the routine vision care benefit. This ultimately can deny the patient the full scope of care promised to them under Medicare.”

In the letter, he explains that forgoing care can result potentially in sight loss and blindness, never mind the impact on society—patients’ inability to perform daily living tasks, increased risk of falls and fractures, negative mental health and reduced quality of life and life expectancy. These negative impacts are especially concerning, he says, because of the growing prevalence of age-related eye diseases.

Aside from staggering prevalence projections, Dr. Layman says, at least 40% of vision loss in the U.S. is either preventable or treatable with timely intervention. MA plans should take additional steps to ensure this at-risk patient population in particular understand the range of benefits available to them, he says.

"The AOA wants to make sure that any revenue increase in Medicare Advantage plans is directly transferred to patients via improved benefits and care,” says Robert Theaker, O.D., chair of the AOA Federal Relations Committee. “One problem many doctors of optometry encounter is a Medicare Advantage patient who comes into the office for an eye exam and glasses (which the MA plan has subcontracted out to a vision plan), but then the patient avoids additional care related to eye disease that has been identified because that portion is managed by other providers unrelated to the routine vision care benefit.

“This inefficient system does a disservice to both patients and doctors of optometry,” Dr. Theaker says. “In addition, the AOA is looking for better oversight of MA plans in regard to reimbursement and network selection of optometrists so as to avoid provider discrimination.”

Adds Steven Eiss, O.D., chair of the AOA Third Party Center Executive Committee:

“It is essential that we as an organization reach out to payers, such as CMS, when these opportunities arise, to ensure optometry and eye care is not an afterthought. In the realm of Medicare Advantage plans, we are seeing more instances of these plans marginalizing eye care by removing it from the medical plan and compartmentalizing into separate vision plan panels. This is often confusing to the patients and fragments their care. We feel it is of the utmost importance that optometry and eye care be integrated into the medical plan and continue to be part of the medical panels. We need to prevent situations where patients have to seek out different providers for different aspects of care due to fragmented provider panels. Continuity of care, regardless of whether the patient is in need of a refractive or a medical examination, will help to achieve better patient outcomes and satisfaction.”

Discriminating against doctors of optometry

Under Section 1852 of the Social Security Act, beneficiaries of MA plans are entitled to have their plan free from discrimination against doctors of optometry with respect to participation, reimbursement or indemnification. MA plans typically subcontract with managed vision care companies and require doctors of optometry to contract with the vision plans. Yet, Dr. Layman says, ophthalmologists may contract directly with the MA plan. That is a violation of the act, he says.

“This harms patients’ access to statutorily required benefits as well as the supplemental benefits promoted by MA plans, and further exacerbates medical loss ratio obligations,” he says.

The AOA also asks CMS to address what it described as a “longstanding inequity” in CMS guidance—MA plans are required to contract with a certain number of ophthalmologists but do not demand an “adequate network” of optometrists.

“Given the proposed increases for 2023, we believe that more should be expected from MA plans, and we urge the agency to enforce these rights for patients,” Dr. Layman concludes. “We urge CMS to support Medicare Advantage models of care coverage that embed and coordinate preventive eye care into the holistic health of the patient and eliminate the bifurcation of eye health and vision care benefits, focusing more fully on meeting the complete eye health and vision needs of the patient.”

Call to action

To continue to advocate for appropriate reimbursement under Medicare and avoid additional cuts, contact your lawmakers via the AOA Action Center. Use a pre-populated message expressing these important concerns or text “PAYMENT” to 855.465.5124 to access the Action Center on your mobile device.

Also, join optometry’s advocates in Washington, D.C., at the joint AOA on Capitol Hill and AOA Payer Advocacy Summit, April 24-26, for the single-largest annual advocacy experience.