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ACA Mandate Makes More Kids Eligible for Comprehensive Vision Care

Insurers must now cover pediatric eye exams that go far beyond basic screening

eye exam

Vision problems in children can lead to serious difficulties in school and life, from poor reading comprehension and test scores to higher rates of juvenile delinquency and unnecessary placement in special-needs programs, especially among poor children.

New Jersey schools are required to provide students with periodic vision screenings, but optometrists argue that they often don’t result in needed treatment.

Screenings at schools and in pediatricians’ offices, while less expensive and easier to administer, typically are limited to checking how well a child can read an eye chart and other tests of visual acuity.

Even when those screenings flag children for poor vision, their parents often do not take them to the eye doctor, because of the cost or for other reasons.

But the dynamics of pediatric eye care may begin changing this year, as families start taking advantage of the new pediatric vision benefit in the Affordable Care Act. Under the law, Americans are now required to have health insurance and all policies must cover vision care for children – including comprehensive eye exams – at no additional cost.

Exams performed by optometrists and ophthalmologists check peripheral vision and color vision, as well as how well the eyes move and work together, in addition to visual acuity, said Dr. Maria Richman, president of the New Jersey Society of Optometric Physicians. The tests often include dilation to allow the doctor to look at the back of the eye and check the health of the eye.

“We'll look at a refraction to see if they're nearsighted or farsighted, or to see if they have astigmatism or a lazy eye – maybe one eye needs a prescription and the other eye doesn't,” Richman said. “Screenings do not pick up any of those things.”

In addition to comprehensive eye exams, the ACA benefit covers glasses, or contact lenses if deemed necessary. Policies also pay for treatment of children’s eye health problems such as a scratched cornea or pinkeye, which is often also covered by medical insurance. Plans are not required to cover vision therapy.

Richman said catching vision problems early is important because, if uncorrected, they can interfere with learning. For example, a misalignment that causes a problem with eye “teaming,” or the coordination of the two eyes, can interfere with reading of words and numbers.

“When that happens, they lose their place, they skip a line,” Richman said. “Maybe if they're learning arithmetic and they're trying to read a column of numbers, they might be skipping over it, or carrying it onto a different column instead of the column next to it.”

Optometrists argue that the Affordable Care Act’s effort to make periodic full exams the standard for children, rather than just basic screenings, is justified by the long-term effects of untreated vision problems.

“That’s why it’s so important to have a comprehensive eye exam and that's probably why it was included in the essential pediatric vision benefit,” said Richman, who has a private practice in Manasquan.

Not all doctors agree. Some ophthalmologists (who specialize in surgery and treating eye diseases) and pediatricians have argued that less expensive screenings are sufficient to catch problems in young children.

Douglas E. Mazzuca, Sr., president of the New Jersey Academy of Ophthalmology, said screenings can distinguish early on between kids who have normal vision and those with problems that require annual comprehensive exams. At the same time, he agreed that the new essential benefit will likely help many children.

“Ophthalmologists, along with optometrists, are going to have more pediatric eye exams than we used to. It’s a good thing on the whole, when you look at the entire picture,” Mazzuca said. “It may be a bit costly, but I think it’s generally good, especially for the kids who aren’t getting any coverage now. They’re getting no exams.”

Richman said about half of New Jersey children age 18 years old and younger already have vision care coverage through employer plans, private plans or NJ Family Care.

While the figure suggests that many more children could be heading to eye doctors for checkups in the coming months and years, she said the state’s 1,200 licensed optometrists should be able to handle any increase.

“About 50 percent of the kids already have this, so we're not really anticipating a surge of new patients,” she said. “We have the manpower to handle this.”

The pediatric vision coverage that must now be embedded in health insurance plans is actually administered by separate vision care companies. In New Jersey, the three insurers selling policies through the federal health insurance exchange — AmeriHealth, Health Republic and Horizon — partner with Davis Vision, a subsidiary of Highmark, giving customers access to optometrists and optical stores around the state.

“There is a trend now where the vision care plans are partnering with the medical insurance providers and are part of the package, so to speak,” NJSOP executive director Howard Cooper said.

In addition to the required pediatric benefit, AmeriHealth offers enhanced plans that provide higher reimbursements and other optional benefits for an additional fee, said Mike Munoz, the company’s senior vice president of sales and marketing. Adult vision coverage is not required but is also widely available for purchase.

Munoz noted that historically the choice of whether to include vision in a health care plan has been made by an individual’s employer. He said it is too soon to tell how popular the required pediatric benefit will be with consumers.

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