Insurers: ACA demands full reimbursement for kids' eyewear


WALLA WALLA — Few could have seen it coming, not even eye-care professionals.

Due to interpretations of new federal health-care laws, some local children are leaving optical shops with expensive designer frames and the best lenses money can buy.

Insurance money, that is.

According to insurance and vision sources, some plan options with the largest insurance companies in Washington state are allowing patients 18 and younger the run of eyewear display cases. From the very inexpensive to the very best, kids are picking out whatever glasses and contacts they wish, thanks to some interpretations of the Affordable Care Act.

And word is getting out, said Brent Dunn, business manager for Valley Vision Clinic, where frames can range from $49 to $700 or more.

“People are definitely taking advantage of it,” he said.

Dunn was referring to a tenet of health-care reform called “essential health benefits.” There are 10 in the new health insurance landscape, all immune to the cost caps traditionally set by insurance companies.

Pediatric vision services is among the 10, and all qualified health plans must offer it to participate in health insurance exchanges.

The benefit has solid roots, Dunn said.

“It was intended to make sure children get proper eyewear and to prevent eye damage over time,” he said. “Part of the law was to help catch things before they got too bad.”

Many employer-based insurance plans in this state and others have long had allowance-based models with the same goal of regular checkups. A typical plan would pay for eye exams once a year and allotted a set figure for new glasses or contacts every two years for kids and adults alike. Anything above that line would be paid for by the consumer, Dunn explained.

“An average pair ... is $200-$300 for a nice frame and lens,” he said.

And that’s how things remain for adults. But for children in Washington, Group Health, Premera and Regence insurance companies — at least — have interpreted the “no out-of-pocket” limit for this essential benefit to mean they will pay “100 percent of billed charges of regular or deluxe glasses” on some workplace-based insurance plans, he said.

At eye level, deluxe options can stack up financially. Added to the price of even the most expensive frames are lens customization with such features as sun-blocking, anti-glare, anti-scratch and other coatings that will significantly raise the cost.

Children enrolled under state-covered insurance plans don’t reap the same benefits.

“Basically for children (Medicaid) covers basic frames and lenses and are not seeing those ‘no cap’ plans,” Dunn said.

With five doctors on staff Valley Vision Clinic sells a lot of glasses, increasing the importance of fully understanding the new health-care law, Dunn pointed out.

“We called each of these insurance companies,” he said. “We verified this is what they are saying, that kids can choose whatever they want. We’re so used to dollar limits or discount plans, so when this came along, we really weren’t forewarned.”

As people who wanted to use the benefit began coming in and getting “very nice” glasses for their children, Dunn said, he and others worried about potential insurance fraud issues for every vision business in this situation.

“We want to make sure things are correct for our patients so we did a lot of research,” he said.

What they found seems to be the opposite of good economic sense, Dunn added.

As Group Health Cooperative, Regence and Premera Blue Cross view the rule — they are three of the private insurance companies Valley Vision works with most — children can get what they want in the optical shop, or at least what their parents will let them have.

“We’re torn,” Dunn conceded. Valley Vision could potentially see more designer frames such as Christian Dior, Diva and Caviar to go out the door on young faces, but it’s not the spirit of the law, he said.

Asked for comment, Regence spokeswoman Rachelle Cunningham said in an email that the company had previously paid a set amount for eyewear until this year, when “the (Washington state) Office of the Insurance Commissioner mandated no cost sharing.”

Stephanie Marquis, spokeswoman for Washington state’s Office of the Insurance Commissioner, said that keeping children’s eyes healthy is the reason rule was enacted Jan. 1. But insurance companies are given leeway to create levels of coverage for eyewear, as long as there a base level that provides a free set of frames or free contact lenses once a year for those younger than 18.

Insurance companies are free to decide a dollar mark for eyewear once that condition is met, she explained.

“If the insurance company has decided ‘no cost sharing’ on any frame, that’s their decision, not one we have mandated,” Marquis added.

Premera Blue Cross spokesman Eric Earling said there is no question companies and individuals continue to work toward full understanding of all the Affordable Care Act means. But given the law’s expansive scope, two things are becoming clear — more people are getting health coverage and the law is not doing enough to address rising medical costs.

And, as with any change, there will be unintended consequences, he added.

Such as those pediatric vision benefits, which Premera interprets as unlimited choice for kids in eyewear once a year.

When asked if Premera pays for whatever eyewear a child chooses as part of a marketing plan, Earling said insurance shoppers are really looking at the “nuts and bolts” of medical coverage. Vision and dental care are smaller cogs and not as likely to be the primary focus of consumer attention, he said.

The benefit, like other parts of the ACA, is bound to be reconsidered by every health plan on the market at some point, Earling added.

“We will definitely take a look at what’s working and what’s not,” he said.

Group Health Cooperative did not respond to a request for comment about its pediatric vision policy.

Dunn said Valley Vision’s staff believes the boundaries of the pediatric vision benefit will be better defined by officials as time goes on.

“The law is well intended, but most doctors would agree there should be a limit,” he said. “We’re definitely not advertising this benefit is there, we feel there should be a cap. We’re concerned about the perception of this.”

Sheila Hagar can be reached at or 526-8322.



NewInWW says...

So far as I can tell, no one from the federal government has said insurers must cover designer frames. Am I missing something?

Posted 9 March 2014, 11:12 p.m. Suggest removal

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