Essential Health Benefits Coalition Requests Reduction in Pediatric Vision Benefit


WASHINGTON, D.C.—A group called the Essential Health Benefits Coalition (EHBC) sent a letter to the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS), requesting that it reduce the requirements in the final Affordable Care Act’s essential health benefits rule, including those regarding pediatric vision care. Pediatric vision care is one of the essential health benefits currently included in the Affordable Care Act.

The Essential Health Benefits Coalition describes itself as “a broad-based organization representing large and small employers from various sectors of the U.S. economy, pharmacy benefit managers, and health plans operating in every state.” Among the organizations who signed the letter from the EHBC are the American Academy of Ophthalmology, the National Retail Federation, the Blue Cross and Blue Shield AssociationAmerica’s Health Insurance Plans, the  Pharmaceutical Care Management Association and the National Association of Dental Plans.

In the 11-page letter, the EHBC objects to the HHS proposal that for those states in which its health insurance benchmark lacks pediatric vision care that it be supplemented by the addition of benefits from either the Federal Employees Dental and Vision Insurance Plan (FEDVIP) or by benefits available under the state’s separate CHIP plan. (This HHS proposal was originally reported by the article HHS to Give States More Flexibility to Set ‘Essential Health Benefits' on Dec. 19, 2012.) The EHBC sent the letter to HHS on Dec. 21, 2012, just prior to the Dec. 26, 2012, deadline for comments on the HHS proposal.

Instead of the HHS proposal, the EHBC recommends “allowing supplementation with a benefit that follows American Academy of Pediatrics’ (AAP) and Bright Futures recommendations for preventative vision screenings with referral for necessary vision, medical and surgical care for potential problems as needed.” (Bright Futures is a national children’s health promotion initiative in collaboration with AAP and federally and state-funded projects.)

Specifically, these recommendations call for: “1) a risk assessment with appropriate action to follow if positive at the newborn evaluation, three- and five-day follow-up visits, and at the one-, two-, four-, six-, nine-, 12-, 15-, 18-, 24- and 30-month well baby visits; 2) a screen at age three with a rescreen within six months if the patient is uncooperative; 3) a screen at ages four, five and six with a risk assessment at age seven; and 4) in general, alternating a screen and risk assessment beginning at age eight years. If a risk assessment indicates a potential issue, an eye examination including refraction would occur.”

The EHBC letter further states, “Should HHS retain its proposed approach for pediatric vision, the EHBC recommends that in the final rule HHS clarify that issuers may require a referral from a primary care provider, school or health department prior to receiving FEDVIP or CHIP vision benefits. The referral should identify the need for additional care following a screening/risk assessment consistent with AAP and Bright Futures guidelines.”

In response, the American Optometric Association said, “The anti-access coalition’s pediatric vision care recommendations stand in direct contrast to what the AOA, Congress, and HHS know the benefit needs to be for America’s families. In the ongoing legislative and regulatory battles in Washington, D.C., the AOA has successfully advocated to make expanded and direct access to comprehensive eyecare a national health care priority and to ensure that coverage for at least an annual comprehensive eye exam and follow-up care is the foundation of the newly created pediatric vision essential benefit. Ophthalmology and insurers have actively opposed the AOA at each step of the process and are now pursuing a last-ditch effort to roll back eye health and other coverage requirements before they can take effect next year.”

The AOA calls the EHBC’s recommendation a “gaping loophole,” further stating, “In an apparent effort to create a new gatekeeper system, the group’s recommendation would universally require that kids first fail a vision screening before gaining access to any other eye and vision care service. Acknowledged research and OD experience show vision screenings miss most eye and vision problems, and even those identified by a screening often remain unresolved because, tragically, the appropriate transitions into care do not usually occur.”

While HHS does not have a specific date on which it will release its final essential health benefits ruling, it is expected within the next few months, perhaps as early as February or March.