AOA Managed Care Marketing Initiative Success Stories

AOA alerts top Medicare official to plans excluding optometry

February, 2006

Herb Kuhn, the top Bush Adminstration official in the Center for Medicare Management of the U.S. Department of Health and Human Services, and Jon Hymes, AOA Washington Office Director, met to discuss the AOA Eye Care Benefits Center (AOA-ECBC) report on access to optometrists through the largest Medicare Advantage HMOs and PPOs.

AOA’s Washington Office sought this meeting to formally present the report to Medicare officials and to specifically identify 11 Medicare Advantage plans found to exclude ODs, as well as 37 others being scrutinized further by an ongoing AOA-ECBC access iniatiative. Kuhn pledged to review the AOA report’s findings and take appropriate action in any instance in which optometrists are being improperly excluded from Medicare plans.

Bell South to Start Covering OD Services

December, 2005

In an abrupt turn-around, Bell South has published in their plan description that medical eye care services provided by optometrists within the scope of their licenses will be considered eligible expenses by the Basic PPO, POS, and Basic Indemnity Plans. What this means is another significant ERISA win for optometry and potentially 200,000 more beneficiaries who can receive medical eye care from their optometrists. The AOA Eye Care Benefits Center (ECBC), along with the Alabama Optometric Association, Georgia Optometric Association and others, has been working on this for at least three years.

Mark Hennen, O.D.,chair of the ECBC Executive Committee said, “This is a big win not only for optometry, but for the employees of Bell South and their families, as well. The coordinated efforts of the AOA, the Alabama Optometric Association, and the Georgia Optometric Association paid off with a benefit to all involved.” The previous exclusion of optometrists from reimbursement has been a top priority.

Bell South is self-funded and uses United Health Care and Blue Cross of Alabama as their primary administrators. According to ECBC, if an optometrist is already on these panels he or she should not have to do anything further to remain a panel member. If not, optometrists will need to apply with these two organizations to be in their networks.

CIGNA of Tennessee to Reimburse ODs for medical eye care

September 2005

A joint AOA and Tennessee Optometric Association initiative is producing results following a decision in late August by CIGNA of Tennessee to invite optometrists in the Volunteer State to participate in the CIGNA network. The ongoing implementation of CIGNA's decision to include ODs – which is being closely monitored by the AOA and TOA – represents another victory for ODs and their patients through optometry's Managed Care Marketing Initiative, a program of the Washington, DC-based AOA Eye Care Benefits Center (ECBC). ECBC is continuing to work in partnership with state affiliates to identify and respond to managed care plans that exclude ODs.

ECBC reports on Aetna reimbursement change

April 2005

For the last few years, it was Aetna’s clinical policy to deny Retinal Nerve Fiber Layer Analysis (CPT 4 Code) 92135. This was based on a Technology Evaluation Center determination that the procedure was experimental. Things have changed.

Thanks to the efforts of manufacturers, researchers, and work done by AOA’s Eye Care Benefits Executive Committee, we have been informed by Rory O'Brien of Heidelberg Engineering that Aetna has now accepted the use of Retinal Laser Scanning.

Aetna has been under pressure because the procedure is now the standard of clinical care for glaucoma and because of the Technology Evaluation Center reversal—a decision based on current studies—particularly a study by Linda Zangwill, PhD.

ECBC hopes this will clear the way for reimbursement of CPT code 92135 by all payers.

Summary of MCMI victories since 2002