How Should Exchange Handle Vision, Dental Coverage?

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TOPIC ALERT:

Along with medical coverage, state-run health insurance exchanges under the Affordable Care Act have the option of offering vision and dental coverage.

This summer, the California Health Benefit Exchange elected not to offer stand-alone vision plans. That brought a chorus of criticism and now the exchange is planning to revisit that decision.

The Affordable Care Act provides some guidelines for vision and dental coverage -- guidelines that differ for children and adults. But as it does with medical coverage, the ACA leaves the details pretty much up to state officials.

We asked stakeholders and consumers how the California Health Benefit Exchange should handle dental and vision coverage.

We got responses from:

  • Kimberly Cockerham and Craig Kliger | President, and Vice President, California Academy of Eye Physicians and Surgeons

    Roadblocks for Stand-Alones Not Insurmountable

    The stand-alone vision plan has long been a staple for many to receive vision services that have not traditionally been covered by standard medical insurance.

    Inclusion of these plans in the offerings of the California Health Benefit Exchange is therefore reasonable and important to the degree they would be "add-ons," as this could stimulate competition and improve affordability in both the small business and the individual exchange markets.

    However, end-of-session legislation (AB 1453 and SB 951) establishing the minimum "benchmark" for essential health benefits as the Kaiser Foundation Health Plan Small Group HMO 30 plan -- which includes coverage for the examination services stand-alone plans would provide -- appears to make stand-alone plans nonviable in either market. This is because standard medical insurers appear unable to divest themselves of the responsibility to provide all coverage elements of the Kaiser plan. In fact, the law seems to go out of its way to ensure they can't.

    Thus, standard medical insurers must reasonably receive (and control) the related premium or subsidy to enable them to exercise that responsibility. In short, unless we are somehow overlooking language that allows an exception, it does not appear that such amounts can actually be "[split] between the individual's main insurance and vision coverage" by the exchange as was its board's concern as indicated in prior California Healthline reporting.

    Given that the "benchmark" plan for the pediatric vision benefit also requires coverage for glasses and contact lenses, a stand-alone plan for that purpose would wholly duplicate covered services. Similar problems appear to exist for stand-alone plans desiring to provide the pediatric oral care benefit.

    Indeed, stand-alone vision plans could offer a product covering only glasses and contacts for adults. However, given that such a product would likely be attractive only to those known to need such items (meaning essentially 100% of those enrolled would actually use the coverage), that option probably wouldn't be actuarially or financially tenable.

    The good news is that nothing in the legislation appears to prevent standard medical insurers from contracting with stand-alone plans to provide required (or even optional) benefits, and indeed many such insurers currently do this voluntarily as a means of making their plans more attractive.

    If there is a legislative "escape valve" we are missing, the exchange should add stand-alone plans to both types of exchanges. But, if not, allowing direct access to stand-alone plans through the exchange at this point would appear to require the Legislature and the governor to permit the needed payment flexibility.

    That is a change we could easily support.

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  • Dan Davidson | President, California Dental Association

    State Needs Stand-Alone and Supplemental Dental Plans

    CDA was pleased to see pediatric dental benefits included as one of the Affordable Care Act's Essential Health Benefits that will be offered through the California Health Benefit Exchange. California took the first step in implementing this policy by passing legislation sponsored by Sen. Ed Hernandez (D-Los Angeles) and Assembly member Bill Monning (D-Santa Cruz) to define dental benefits so that they will mirror those included in the Healthy Families Program. CDA supported the adoption of the Healthy Families pediatric dental benefit because the benchmark has a proven track record of meeting the oral health needs of California children and the professional standards of California dentists. 

    The next major step for California related to dental benefits in the exchange is to define the parameters within which dental plans must create benefit packages for sale in the exchange.

    CDA has urged the exchange board to offer adult dental benefits through the exchange. While children's dental benefits are part of the Essential Health Benefit packages that must be sold, adult dental benefits are called "supplemental," and the exchange may choose whether to offer them. Offering adult benefits will allow the exchange to be the central location for comprehensive access to health and oral health benefits for both children and adults. 

    The other key dental benefits question relates to the issue of stand-alone plans. The exchange board will decide whether children's dental benefits will be offered by stand-alone dental plans, by health plans as an integrated part of a medical benefits plan, or both. Dental benefits are fundamentally different from medical benefits and are best described as a "prepaid" benefit with capped limits rather than a capitated medical model that covers all medically necessary services on a risk basis. Offering stand-alone dental benefits would reflect the current marketplace as there is virtually no existing model of integrated benefits. Offering a variety of benefit options, including those provided by stand-alone dental plans, will ensure consumers have adequate choice of dental plan coverage.

    Adoption of both stand-alone and supplemental adult dental benefit plan designs is the next critical step the state needs to take to effectively implement the ACA in California. It will ensure implementation of the dental benefits that meet the needs of dentists and their patients and set up a system that will provide access to much needed dental care for all those who access coverage through the California Health Benefit Exchange. 

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  • David Chase | California outreach director, Small Business Majority

    Comprehensive, Robust Offerings Make More Sense

    The health insurance exchanges are one of the most -- if not the most -- important components of health care reform for small businesses. A well-designed business exchange can lower small businesses' insurance costs, offer them and their employees more choices of plans and reduce the burden of administering those plans.

    The Affordable Care Act gives states quite a bit of leeway in setting up their exchanges. For instance, states can have one exchange for everyone or split the exchange into two categories, one for individuals and one for small businesses. California is creating one specifically for small businesses -- the Small Business Health Options program, or SHOP. Fortunately for the state's small employers, the Golden State is far ahead of the curve. The more time a state takes to set up its exchange, the better suited for its customers it will be when it opens, and ultimately more successful in the long run. 

    That's why Small Business Majority has been involved in the creation of the state's SHOP exchange from the get-go. In fact, one of our small business Network Council members, a small business owner from San Francisco, sits on the SHOP advisory work group.

    Various issues have been raised over the course of setting up the SHOP exchange, including whether stand-alone vision and dental plans should be included -- a debate currently dominating the individual exchange landscape.

    We supported including vision and dental plans in the SHOP exchange because it's important the SHOP be a true, one-stop shop for small businesses. We know from looking at other successful small business exchanges that this "one-stop shop" model is the most effective. Take, for instance, the Connecticut Business and Industry Association exchange, which has 5,500 employer members, 80,000 covered lives and 16 years of experience. 

    The Connecticut business exchange offers a variety of necessary services for employers in a one-stop shop, uses brokers to distribute products, utilizes an employee choice model and has avoided adverse selection by continually improving plan designs and monitoring the outside market. They became one of the most successful small business exchanges in the country by learning and reacting to the needs of Connecticut's small business owners. So far, California's SHOP is on track to do the same. 

    From a small business perspective, the more comprehensive and robust an exchange can be, the more people will take advantage of its services. Employers would be less likely to use an exchange if they purchase one type of insurance through it but have to go elsewhere to purchase the rest. And the bottom line is, the more people using it, the more successful the exchange will be in lowering costs.

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  • Movses D'Janbatian | President, California Optometric Association

    Stand-Alone Vision Plans Should be Offered in Exchange

    The California Optometric Association has been on the cutting edge of providing high quality health care to the people of California for more than a century. 

    Our goal is to assure the public that our doctors care deeply about our patients and want Californians to have viable options.

    As president of the COA, I speak for thousands of doctors when I express support for the inclusion of stand-alone vision plans in the California Health Benefit Exchange. It is a sensible position premised at least in part by the realization that many Californians presently receive their vision coverage through a stand-alone plan. 

    Let's consider the impact. 

    Most vision care coverage in California comes through a stand-alone vision plan. Any transition excluding this structure may inevitably create confusion as millions of patients confront the prospect that their doctor may not be included as providers in their health plan.

    As such, COA also supports requiring Qualified Health Plans (QHPs) to contract with an adequate number of optometrists in order to provide coverage for the pediatric vision essential benefit. It is equally important that QHPs contract with doctors of optometry to ensure Californians are afforded access to appropriate comprehensive eye care.

    As an optometrist with decades of experience watching the evolution of health care in California, I think it matters that the exchange require QHPs to coordinate vision and medical eye care regardless if it is provided by a stand-alone vision plan or as a plan embedded in a QHP. When full service plans contract for vision care separately, doctors of optometry are sometimes prevented from providing medically necessary eye care that is diagnosed during a routine exam. At best, the patient is inconvenienced because he or she has to make an appointment with another doctor and go through a duplicate set of tests. At worst, the patient ends up paying for services that should be covered or electing to not receive care.

    It is fundamental that doctors of optometry be allowed to provide all services within their scope of practice. Optometric services should be integrated into other medical services even if doctors of optometry are contracted with the QHP through a vision plan. This kind of care coordination will expand access, improve patient outcomes, and minimize or eliminate duplication.

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julie anderson
We can choose best policy to cover these items!It is better to consult the agent which best suits us and saves the money too!
Hrant Kouyoumdjian
Plus ça change, plus c'est la même chose! Two key words in the first para "Affordable" and "option;" the former was not addressed and the latter was glossed over in the stakeholder responses which did not include consumers! From a strictly market driven consumers' economic policy perspective, free choice is king but so is income/price elasticities which we have advocated before on this forum. Without the latter two, choice as an option is meaningless. HBEX benefits outside mandated ones are best offered as supplemental benefits via stand alone and/or part of QHPs. Let insurers and providers sort out which is more marketable/sellable for both seem quite eager to participate in this new market opportunity; given their vocal enthusiasm, subsidy implementation details can be worked out. Consumers can then decide if they want such supplemental benefits and which delivery option best meets their needs financially and clinically. This is the true power of market driven affordable choices.

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