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Healthcare Reform 101
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New Insurers and Plans in Maryland's Exchange

Individual Market

July 2013 - Maryland Insurance Commissioner, Therese M. Goldsmith, announced that the Maryland Insurance Administration (MIA) had approved premiums rates for individual health benefit plans being offered through the Maryland Health Connection. Learn more about Maryland health insurance carrier rates.


Small Group Market

September 2013 - Maryland Insurance Commissioner announced the MIA had approved policies and premiums for plans to be sold through Maryland’s Small Business Health Options Program (SHOP) Exchange. According to the Sept 17 press release, thirteen carriers applied to sell plans in the small group market. Learn more about the carriers and approved 2014 premium rates for the small group market.

New Health Care Delivery Systems and Models

As a national leader of health care reform, Maryland is moving toward suggested models of health care delivery that demonstrate collaborative, comprehensive, and coordinated patient care. The two most commonly accepted models to achieve quality based outcomes and reduction of costs associated with health care reform are Accountable Care Organizations (ACOs) and Patent-Centered Medical Homes (PCMHs). Both models fseek to answer: What is an ACO? What is a PCMH? And more importantly, can optometrists be a part of these new health care delivery systems?

The ACO has been compared to unicorns…"everyone's heard of them, but no one's seem them." The ACA recognizes (Section 3022) an ACO as a model in which providers form an organization and assume responsibility for all care delivered by their providers. The goal is to reduce Medicare costs while maintaining quality in patient care; and for this Medicare has agreed to share in the ACO's savings. A listing of all the ACOs in each state (including 10 Maryland ACOs) is available on the American Academy of Physical Medicine and Rehabilitation website.

The PCHM, much like the ACO, is quality and cost-efficient health care delivery system, but typically smaller. It also emphasizes the importance of coordination of care, but through a primary care physician led team. Cost savings is achieved through focus on preventative services and streamlining of administrative processes. Learn more about Maryland PCMH sites and the Maryland Multi-Payer Patient Center Medical Home Program.

Can ODs participate in new these new healthcare reform-driven delivery systems and models?

Yes! Although these new systems are designed to coordinate care through a patient's primary care provider (PCP) the essential goal is to improve a patients' overall health, including eye and vision health. As a national leader of healthcare reform, Maryland applied for, and received a $2.37 million "Model Design Award" from CMS to develop a Community-Integrated Model Home. The State will now apply for a $60 million "Model Testing" Award from CMS to fund the implementation of its design. Learn more about Maryland's plans to move toward aCommunity-Integrated Model Home.

What optometry can do to ensure relevance in the changing landscape of healthcare reform

Participate in any CMS Program/Initiative that recognizes ODs as eligible providers. All new models of health care deliver require communication between participating providers, so most importantly, ODs need to adopt the use of Electronic Health Records into their practices. Read the AOA article "Prepare now for Health IT milestones in 2014" so you know what lies ahead.

New Eye Care Provider Contracts & Reimbursement Fees

What to do, what you can and cannot say and how to avoid anti-trust violations

There has been much hubbub as of late about new provider contracts and reimbursement rates related to eye and vision care services and material benefits as insurers adjust old, and submit new, plan designs to address healthcare reform demands.The AOA and MOA urge optometrists to be careful about commentary on this subject.

What should you do? You should read any new contract very carefully, including an addendum if referenced. Your should look at the fee schedule associated with any contract you sign and if one is not included, request a copy. If you are unsure about any provision or language within a contract, consult an attorney prior to signing. In short, you should know exactly what you are signing. After all, you wouldn’t sign a contract to buy or lease a car without first thoroughly reading and understanding the terms. Right?

What shouldn't you do? Discuss specifics about a grievance related to a particular insurer's new contract or third party's reimbursements in any public forum. The AOA has a comprehensive well written article on this topic that outlines how to avoid Anti-Trust violations, which we highly recommend reading. Read the AOA article.

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