The New 2019 Diet: "Skinny" Health Insurance Plans & Optometry
Bryan M. Rogoff, OD, MBA, CPHM, FAAO
As we approach 2019, open enrollment is on its way for patients with employers, public exchanges and now, open marketplace. Although the Affordable Care Act was never repealed, a big change was the elimination of individual mandate. New association health plans were also reintroduced into the market. AHP plans, also known as "skinny" plans, are much cheaper than ACA plans and are becoming more appealing to consumers. AHP plans have been around for decades and were drastically reduced to a small sliver of the insurance market after passage of the ACA in 2010. These plans do not have as much comprehensive coverage compared to the ACA plans.
In June 2018, the US Department of Labor released a final rule that allows small businesses and entrepreneurs to band together for the purpose to purchasing "skinny" health insurance plans at a lower cost.1 These plans are usually not subject to state insurance regulations because essentially, they are not insurance plans. They are catastrophic plans that do not have the 10 essential benefits that are found on ACA exchanges. These cheaper policies attract lower-risk, healthy people from the exchanges causing the marketplace risk pools to become predominately people with pre-existing conditions who need constant care.
Changes are also coming from large employer-based health insurance. Mercer, a consulting, brokerage and digital solutions company, reports that employers with 500 or more employees are making changes to mitigate the increase of 5.3% to 4.1% per employee.2 About a third of employers with less than 500 employees saw increases in health insurance premiums in double digits.2
What are employers doing to control the costs of health insurance for their employees?
In the past, employers did several things to reduce their health insurance premium burdens. They reduced the amount of subsidy they would pay for employees and their family’s premiums, as well as enrolling in higher deductible plans. However, there is a loophole in the Affordable Care Act that allows employers to avoid penalties ($2,000 per employee) of the health insurance mandate by offering employees skinny plans.3 This loophole comes from the new final rule which does not explicitly state the definition of "minimum essential coverage", such as in other regulations, and therefore allows large employers to avoid the penalty by offering AHP type plans. These skinny plans basically cover preventative care and limit medical expenses leaving people thinking they have comprehensive coverage for medical diagnostic tests and therapeutic plans.
How will this affect optometry?
Optometry is constantly embracing medical models to increase revenue streams, while also fighting for fair reimbursements. Skinny plans are designed to minimize coverage of medical conditions and some of these might include ocular medical conditions. Since premiums are based on the likelihood and the size of health risks, patients take on more risk and may not anticipate having certain ocular medical conditions occurring. Also, the employer can now limit coverage depending on the severity of vision loss. As eye care providers, we typically blame the insurance payer for not covering diagnostic and therapeutic codes, but now employers and associated health plans have this control. An employer may not feel it is necessary to cover non-sight ophthalmic conditions such as dry eye and ocular surface conditions. It is important for eye care providers to understand patients’ covered conditions as they make diagnoses.
Bryan M. Rogoff, OD, MBA, CPHM has a unique background in areas of holistic eye care, business management and healthcare reform. He specializes in LEAN clinical management and operations, technology implementation, healthcare strategy, and strategic partnerships. Currently, he serves as a consultant for for the FDA, Immediate Past-President & Education Chairperson for the Maryland Optometric Association, Federal Keyperson and Meetings Committee Member for the American Optometric Association, reviewer for the Council on Optometric Practitioner Education and is the Founder of Eye-Exec Consulting, LLC. To contact Bryan, visit www.eye-exec.com or email firstname.lastname@example.org. He can also be found on LinkedIn, Facebook, Twitter and Instagram.