• Children’s vision benefit. The legislation specifically includes vision care for children as an essential health benefit—but it doesn’t define or even suggest what that benefit will include. “We’re going to have to work with the regulatory bodies in Washington, D.C. to figure out how this essential children’s benefit will be delivered,” says AOA President-Elect Joe Ellis, O.D. “We’re going to be very engaged in this children’s vision care benefit as this enters the regulatory process down the road.”
AOA President Randy Brooks, O.D., adds, “The AOA feels very strongly that this vision benefit should be as expansive as possible and cover comprehensive eye exams, eye health treatment and materials as well … We do not support that this children’s vision benefit should just be a screening.”
The act also adds vision health care services as part of the school-based health clinics program. But again, the regulatory process will define which specific vision services will be included.
• O.D. and M.D. parity. There’s been some confusion that this legislation levels the reimbursement playing field between O.D.s and M.D.s. Not true. But, the good news is that this legislation broadly opens up patient access to optometric care. Starting in 2014, it “will cover optometry with regard to both participation in plans and inclusion of optometrists for any covered services—vision or medical—that optometrists are licensed to provide,” Dr. Brooks says. “That is a huge win. That’s the first change we’ve had in this regard since the ERISA law passed in 1974.” However, the legislation does not mandate equal reimbursement among all providers.
• PQRI and MOC. From 2011 through 2014, the legislation improves the Physician Quality Reporting Initiative (PQRI) by providing an additional 0.5% Medicare payment bonus to providers who successfully report quality measures via a qualified Maintenance of Certification (MOC) program. To be qualified, a MOC program must require participants to: maintain a valid license; participate in educational and self-assessment programs; and demonstrate—through a formalized, secure examination—fundamental diagnostic skills, medical knowledge and clinical judgment to provide quality care in the designated specialty.
This comes as reaffirming news to proponents of optometric board certification, particularly the American Board of Optometry (ABO). “The ABO is encouraged by the recognition of the importance of the ‘formalized, secure examination’ in the MOC process,” says David A. Heath, O.D., Ed.M., treasurer of the ABO.
• Small business benefits. By 2014, states will set up Small Business Health Options Programs (SHOP Exchanges) where small businesses will be able to pool their buying power to get better rates and quality plans. (The Congressional Budget Office estimates that these exchanges would increase coverage and ease small business insurance costs, at least slightly.)
As of 2014, every individual will be required to have health insurance or pay a tax penalty. Also by 2014, businesses with more than 50 employees will be required to provide coverage or pay a fine. However, businesses with fewer than 50 employees don’t have to provide insurance for employees. But if they do, they could qualify for a tax credit starting with the 2010 tax year. This credit is generally targeted for businesses that employ low- and moderate-income workers, according to the IRS.
Specifically, businesses with fewer than 25 employees that pay at least 50% of the health care premiums for their employees qualify for a tax credit up to 35% of premiums. (This credit increases to 50% after 2014 if the insurance is purchased through an exchange). The credit is based on a sliding scale—smaller companies with lower-paid workers (10 or fewer) will receive the largest credit.
Eligibility rules are based on full-time equivalents, not the total number of employees. So, small businesses that use part-time help may qualify even if they have more than 25 employees. Also, wages and hours of physician business owners and partners will not be counted in calculating either the number of full-time employees or the average annual wages, according to the IRS.
