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HHS Proposes Health Care Reform’s Essential Benefits Cover Routine Exams and Corrective Lenses

The Department of Health and Human Services (HHS) released a bulletin on Dec. 16 outlining proposed policies that will give states more flexibility and freedom to implement the Affordable Care Act, including how pediatric vision care would be provided as one of 10 “essential health benefits.” According to the bulletin, HHS proposes that states should consider having pediatric vision care cover “routine eye examinations with refraction, corrective lenses and contact lenses.”

Under the intended approach announced by the HHS, states would have the flexibility to select an insurance plan that reflects the scope of services offered by a “typical employer plan” by using one of the following health insurance plans as a benchmark: one of the three largest small group plans in the state by enrollment, one of the three largest state employee health plans by enrollment, one of the three largest federal employee health plan options by enrollment, or the largest HMO plan offered in the state’s commercial market by enrollment. If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state. Plans could modify coverage within a benefit category as long as they do not reduce the value of coverage.

“Not every benchmark plan includes coverage of all 10 categories of benefits identified [as essential health benefits],” according to the HHS bulletin, which added that among the most commonly non-covered categories of benefits among typical employer plans are pediatric vision services. To determine what pediatric vision services should be offered, HHS reviewed the Federal Employees Dental/Vision Insurance Program (FEDVIP). “The FEDVIP program is a standalone vision and dental program where eligible federal employees pay the full cost of their coverage,” stated the bulletin. “The FEDVIP vision plan with the highest enrollment in 2010 covers routine eye examinations with refraction, corrective lenses and contact lenses. For pediatric vision services we intend to propose the plan must supplement with the benefits covered by the FEDVIP vision plan with the largest enrollment. The rationale for a different treatment of this category is that CHiP [the Children’s Healthcare Program] does not require vision services. We also seek comment on an approach that lets plans define the pediatric vision services with required reporting as a transition policy.”

Public comments are due by Jan. 31, 2012 and can be sent to EssentialHealthBenefits@cms.hhs.gov.

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