Top 5 ACA changes for 2014: Are you ready?

2014 will be a big year for health care reform, with many key parts of the Affordable Care Act (ACA) going into effect. Below are the top 5 ACA changes for 2014—and how each one will affect your practice—based on AOA analysis.

1. Health exchanges for insurance

These are new plans and newly insured people, so you should not lose patients because of the exchange. In fact, you should get new ones.

The insurance sold on health insurance marketplaces was implemented on Jan. 1, 2014. These marketplaces sell health plans primarily to people who do not have insurance. They include individuals and small employers of up to 50 or 100 employees.

What it means for ODs: Because these are new plans and newly insured people, optometrists are expected to gain new patients over time. Evaluate marketplace plans carefully, as you would any other business transaction for your practice. Marketplace plans will have an integrated pediatric vision benefit (see No. 2 below). Optometrists will be needed on provider panels to serve this population and provide medical eye care to the newly insured. Your state's access and nondiscrimination laws will apply to these plans, as will the landmark Harkin Amendment.

2. The pediatric vision care essential health benefit

The pediatric vision benefit is one of the 10 essential benefits that create a basic benefits package for all health plans sold in the marketplaces, plus some plans outside of them. Thanks to the advocacy of the AOA and state affiliates, this is a fully integrated benefit (not a standalone plan) that offers a yearly comprehensive eye exam, plus a materials benefit, for every patient up to age 18.

What it means for ODs: Potentially millions of new patients will have coverage they didn't have before. You may want to advertise to these potential patients and their patients and offer education about the services optometrists provide and the need for pediatric eye exams.

3. Medicaid expansion

Starting in 2014, many states will expand their Medicaid program to everyone under 133 percent of the federal poverty line. Mainly, this will expand coverage to childless adults who generally are not covered in the Medicaid program. States can opt into this expansion or not. It will be fully funded by the federal government for at least three years. States will be getting a lot of pressure from hospitals to adopt the expansion, and the list of states doing so is expected to fluctuate all year.

What it means for ODs: Optometrists who see Medicaid patients will see a significant increase in them. However, although states will get more money for covering this population, that will not necessarily translate into increased payments for providers. States will still face funding issues, which could lead to an increase in Medicaid Managed Care plans in states. If you feel payments are too low in your state, your local affiliate can help you fight to ensure greater access to this vulnerable population.

4. New payment methods

ACOs, PCMHs, care coordination, care transition and managed care—these are just some of the many ideas and acronyms being thrown around as ways to control the rising cost of health care. For example Accountable Care Organizations (ACO) attempt to save money by allowing providers to share in any cost savings achieved through better management of a patient's care. Patient-Centered Medical Homes (PCMH) pay primary care providers extra to better manage a patient's care, usually for chronic diseases such as diabetes.

What it means for ODs: These new delivery models are not necessarily closed systems; you may be participating in one and not even realize it. Organizations that qualify as an ACO or PCMH may refer patients for diabetes-monitoring eye exams to meet certain quality measures. To be an integrated partner in an ACO or PCMH, providers must show value and savings. The AOA is working on materials to help optometrists demonstrate value, but you will need a full-scope optometry practice and a robust medical practice.

5. Changes that affect small business owners

Optometrists will face many of the same health care changes as other small business owners. 

What it means for ODs: The health insurance marketplaces may affect not only the patients you treat but also the people you employ. Visit the AOA's FAQ designed for small business owners—and be ready for coming changes.

January 8, 2014

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