State champs

Excerpted from page 36 of the Summer 2025 edition of AOA Focus 

In February, Arkansas Gov. Sarah Huckabee Sanders signed H.B. 1353 into law, establishing Act 142 of 2025. The legislation delivers sweeping reforms targeting vision benefit managers (VBMs), aimed at restoring patient choice and access, and supporting independent optometry practices at a critical economic time. As of Aug. 5, Act 142 provides the following protections for Arkansas doctors of optometry: 

• Fair reimbursements. Requires that reimbursement rates for covered services and materials be at least that of Medicare rates. 
• Coordination of benefits. Allows patients to combine and coordinate vision and medical benefits to maximize their coverage. 
• Audit protections. Prohibits the use of “batch” or “extrapolation” audits of participating providers; any additional payments due must be based on the actual overpayments or underpayments. 
• Payment freedom. Prohibits VBMs from restricting cash payments to providers when it’s the most cost-effective option for patients. 
• Reimbursement consistency. Prohibits VBMs from reimbursing at a different amount based on providers’ choice of optical lab, health record software or equipment doctors choose. 
• Choice of reimbursement method. Prohibits VBMs from requiring providers to accept forms of payment where a processing fee is assessed in order to get reimbursed. 
• Transparent provider and service listings. Prohibits VBMs from misleading enrollees about what services are fully covered, as well as prevents “steering” of enrollees and “tiering” of providers based on noncovered service discounts or brands of products carried. Also prevents “steering” of enrollees to one provider over another; to any retail establishment affiliated with the VBMs; or to any internet or virtual provider affiliated with the VBM. 
• Increased oversight. Expands the state’s department of insurance regulatory authority by adding VBMs to the definition of a health benefit plan. 

The law represents two significant achievements. First, it was passed with virtually no opposition. Second, it validates what advocates have long argued: The scales are unfairly tipped in plans’ favor. Despite efforts by VBM lobbyists to discredit optometrists, legislators recognized that stagnant reimbursement rates, rising operational costs and anticompetitive contracts weren’t just frustrations—they were threatening patients’ access to care. 

Joseph Sugg, O.D., calls Act 142 a huge victory for doctors and patients. The co-chair of the Arkansas Optometric Association (ArOA) State Legislative Committee says it will help rebalance the scales with VBMs.  

“This law removes influence from insurance companies on where patients receive their eye care,” Dr. Sugg says. “It promotes competition in the vision care market, increases patient choice and access to care by the doctors they prefer to see, and allows patients to use their benefits in combination with their medical insurance. It also strengthens contract terms between doctors and VBMs, and this should only help to further increase patient choice and access.”  

ArOA Legislative Co-Chair Matt Jones, O.D., says the Arkansas affiliate received “wonderful” feedback from members and nonmembers in the weeks following the bill’s passage. It’s also empowering doctors to take action. 

“Taking action to curtail VBM abuses toward providers and patients has really fired up our ODs who now realize that it is up to them to review their contracts, demand fairness and report incidents when the contracts aren’t upheld,” Dr. Jones says. “Act 142 lays the groundwork for action moving forward to allow doctors to negotiate their contracts and choose what materials they offer, and we as the doctors and business owners need to make sure that our staff have the tools to succeed. 

‘Laboratories for democracy’ 

Increasing patient choice and expanding access is the winning combination.  

Consider: Tens of millions of Americans rely on their local doctors of optometry for their comprehensive eye health and vision needs. Yet, despite historic advancements in optometry’s scope and level of care provided, plans haven’t sufficiently advanced alongside the profession. 

Texas’ groundbreaking VBM law, H.B. 1696, approved almost two years earlier in 2023, earned bipartisan support for the same reasons Arkansas’ legislation did. The Texas law addressed grievous VBM policies—such as patient steering and doctor tiering, eliminating chargebacks, noncovered services, audit extrapolation and more—but the law quickly became enmeshed in a legal challenge by VBMs. What’s more, plans began using “evergreen” contracts as a way of circumventing parts of the new law. 

Plaintiffs, including Visionworks of America, Inc., the National Association of Vision Care Plans (NAVCP), Inc., VSP and Healthy Vision Association, sued but failed to attain a temporary restraining order. In March 2024, the lawsuit was brought to the 5th Circuit Court of Appeals, where it remains as of this writing. But that hasn’t stopped the Texas Optometric Association (TOA) from taking action. 

In fact, the TOA doubled down on its advocacy by championing yet another VBM bill that would continue the mission of its first one, including new provisions: 

• Applications for licensed optometrists and therapeutic optometrists must be available online on VBM websites. 
• VBMs must utilize the same credentialing requirements for each applicant and allow each optometrist to be a plan participant to the full extent of their licensure. 
• Not later than the fifth day after the date the VBM receives an application that meets credentialing requirements, the plan must deliver to applicants a contract, including reimbursement fee schedules, provider handbooks and provider manuals. 

“We hope that the Texas legislature will continue to examine what the VBMs are doing, which is walling-off patients into their vertically integrated profit systems and limiting available optometrists from joining networks,” says Thomas Lucas Jr., O.D., TOA’s director of advocacy. “VBMs cannot be in control of doctor or patient decision-making, and they cannot continue to threaten access to care as they have, just to suit their financial interests.” 

All eyes were on Oklahoma H.B. 1979 when it passed in May 2024, seeking to limit plans’ intrusions into the doctor-patient relationship. That’s because the bill represented two hard-fought years of advocacy on the part of the Oklahoma Association of Optometric Physicians (OAOP) when it hit the governor’s desk … and received a veto. But bipartisan and bicameral support for the bill overrode the veto just 23 hours later, literally hours before the end of session. 

“This bill helps us maximize our scope and minimizes interference from VBMs,” said OAOP President Jeff Edwards, O.D., in June 2024. “H.B. 1979 ultimately introduces reasonable, responsible regulations that correct a power imbalance and make sure health care decisions are being made by optometrists and their patients, not vision plans.” 

How the AOA empowers states to act 

Arkansas, Texas and Oklahoma have all secured critical achievements—and if it’s up to the AOA’s State Government Relations Committee (SGRC), they won’t be the last. As steadfast champions of affiliate advocacy, SGRC volunteers and staff provide affiliates with the resources, strategies and connections they need to advance meaningful legislation. 

For three years, the AOA SGRC has convened optometry’s leaders, grassroots advocates and volunteers in workshop-style events, called Regional Advocacy Meetings, to facilitate firsthand collaboration and strategy-building behind optometry’s statehouse advocacy. Meeting topics include not only VBMs but also scope expansion and not-a-doctor efforts, providing advocates a direct opportunity to plan for future success. 

Aside from equipping optometry’s advocates with the resources they need on the ground, the SGRC also seeks to build awareness for issues where state legislators look to collaborate.  

In July 2024, SGRC members presented at the American Legislative Exchange Council (ALEC) meeting, a national forum where state legislators draft and share model legislation. The presentation to ALEC’s Health and Human Services Task Force centered on how VBM policies undermine the doctor-patient relationship, harming both consumers and optometry practices. Later that month, advocates met with a bipartisan group of state legislators who serve on insurance-related committees to continue discussing these critical issues. 

By elevating concerns with influential policymakers, the AOA and its affiliates are expanding the visibility into needed changes. And their efforts don’t stop there. The AOA is also taking direct action to hold VBMs accountable. 

How doctors can empower themselves 

The AOA’s action has already resulted in more than $7.5 million being driven back into optometry practices nationwide, thanks to a strategy to directly intervene on behalf of doctors when they encounter health and vision plan challenges. All doctors have to do is report plan issues to stopplanabuses@aoa.org, and AOA staff will provide support to hasten a solution. 

The AOA receives more than five complaints a week to the email address on average. The most frequent complaint is automatic downcoding, which accounts for half of all issues reported. Unfair reimbursement rates and credentialing issues are tied for the next most-frequently reported issues to the inbox. 

While the AOA is actively taking the fight to plans on behalf of doctors, it’s also equally important that doctors be prepared to advocate for themselves. One place that’s especially crucial: contract negotiations.  

Adhesion contracts, drafted by plans, may contain disadvantageous terms and conditions for doctors, including preempting negotiation. Compounding the issue, plans are increasingly tendering “evergreen” contracts—agreements that automatically renew, locking doctors into unfavorable terms indefinitely. 

To safeguard their interests, providers must carefully review all contracts themselves. Do not rely on a cursory glance or practice staff review to catch the nuances of your contract arrangement. 

It’s also critical for doctors to refer to their provider manual, which outlines the claims filing process, how to submit documentation and how to get reimbursed. Overlooking this document can severely limit a doctor’s ability to challenge unfavorable terms later. 

To promote greater contract transparency, the AOA is urging major vision plans—including VSP and EyeMed—to sign a “Covenant to Transparency in Provider Contracts.” The nine-part agreement includes: 

• Amendment notices. Providers will receive proposed amendments via verifiable means (excluding email) with a 90-day review period. 
• Clearly defined changes. Amendments will be highlighted, tracked and accompanied by a detailed cover letter and a cross-referenced list of changes. 
• Provider inquiry response. Plans will establish a monitored email account for inquiries with responses returned within seven days or an extended review period. 
• Annual agreement updates. Providers will receive the latest plan agreements and policy documents every Jan. 1. 
• Coverage data sharing. Providers will receive an annual update on covered lives in relevant municipalities, counties, states and regions. 
• Fee schedule access. Providers will receive fee schedules in writing with proposed changes in the Jan. 1 update notice. Plans also will establish a monitored email account to request updated fee schedules and plans will respond within 30 days. 
• Dispute resolution access. Providers will have automatic access to plans’ dispute resolution process and advance notice of amendments. 
• Credentialing timeline. Plans will complete credentialing within 60 days and include all participating group practice providers. 
• Covenant duration. The covenant will remain in effect unless superseded by law for greater provider protections. 

Beyond contracting, doctors can also empower themselves—and their patients—by leveraging coordination of benefits (COB). It saves patients time and money, and it ensures doctors receive fair reimbursement. 

“Coordination of benefits is an essential concept that allows patients to utilize the vision benefits that they or their employer are paying for but may not be able to otherwise utilize due to medical conditions that require visits under their medical plans,” explains Steven Eiss, O.D., AOA Third Party Center Executive Committee chair.  

“Although some vision plans already utilize some form of COB, there are specific plan requirements and limitations that may prevent full utilization.” 

The goal of the COB between medical and vision plans is to allow patients to utilize a paid benefit—such as a routine eye exam—when they have a medical eye condition that would preclude them from utilizing the benefit otherwise. Without COB, patients would need to return for a separate office visit, resulting in an additional copay and repeat examinations. 

It’s important to note that COB is only applicable when a medical exam is performed in conjunction with a refraction. In such cases, the claims are billed first to the medical plan. Then, once an explanation of benefits is received, the claims are submitted to the vision plan for documenting copays, deductibles and noncoverage up to the exam’s benefit limit.