Affordable Care Act: Pediatric Vision Services
Pediatric vision services for covered members under the age of 19 are considered essential health benefits as mandated by the federal Affordable Care Act (ACA) as of January 1, 2014. All vision care providers in our networks received formal notice from Blue Cross and Blue Shield of North Carolina (BCBSNC) in the fall of 2013, which included their contract amendment and new fee schedule for lenses and frames. Providers were given 60-days written notice of this January 1, 2014 change in pediatric vision care benefits.
What Is Covered?
The ACA-mandated pediatric vision benefits provide coverage to eligible members under age 19 for the following services:
- One preventive eye exam per benefit period: Covered at 100 percent for eligible group members. Subject to copayment, deductible or coinsurance for individual members depending on their specific benefit plan.
- One pair of lenses and frames OR one pair of nondisposable contact lenses per benefit period: Covered at 50 percent after the eligible member’s deductible is met, if applicable, and if provided by an in-network provider (40 percent if supplied by out-of-network provider).
- Includes fittings
- There is no benefit limit or maximum allowance for the frames. Reimbursement to the provider is based on what the provider pays (i.e., the cost of the frame or lenses); not on the billed amount.
- Standard fee schedule for the frames (not based on UCR)
- Please note that BCBSNC medical policy guidelines will still apply in determining if specific pediatric vision care services are eligible for coverage.
What Is Not Covered?
Disposable contact lenses are not covered by the ACA-mandated pediatric vision benefits.
Who Is Eligible?
The ACA-mandated pediatric vision benefits are available for eligible members under the age of 19, if their plan includes the ACA’s essential health benefits. Please note the following:
- These benefits are included in our ACA-compliant non-grandfathered plans for individuals and small employer groups.
- Large employer groups are not required to cover all essential health benefits at this time, although they may choose to purchase our plans that include them.
- The pediatric vision services benefits were effective January 1, 2014, for individual plans and upon 2014 renewal dates for employer groups.
- Pediatric vision coverage will end on the date of the member’s 19th birthday.
In order to determine whether this benefit applies to a particular member, as well as whether you or the member should submit claims to BCBSNC, you will need to check the member’s eligibility on Blue eSM. Pediatric vision benefits are displayed under the “Vision” category of the “Benefits” tab on Blue e.
Who Is Not Eligible?
Members who have plans that do not include ACA-mandated pediatric vision care benefits, or who are ineligible for the benefit due to age, can continue to benefit from our current optical discount program, if applicable to their specific plan.
How Do I File?
The servicing provider should file the ACA-mandated pediatric vision care services, including lenses and frames, if the patient is an eligible member and his or her plan includes the ACA’s essential health benefits.
- To be reimbursed for lenses and frames, the provider must file the claim with the vision hardware invoice, so that BCBSNC can apply the 3 percent over invoice amount.
- BCBSNC will apply health benefits and reimbursement based on the provider’s contract. When the fee is based on a percentage of the provider’s invoice amount, the invoice amount must be reasonable and the same as what you would charge to the general public.
- Claims filed without the invoice will be mailed back to the provider with instructions to submit the hardware invoice and a copy of claim.
- Member-submitted claims will deny if the provider is participating.
- For nonparticipating providers, BCBSNC will price the claim at charge and pay the member at the in-network benefit level.
- Out-of-state providers should file vision hardware claims to their local BCBS Plan or appropriate intermediary for reimbursement.
Contact your BCBSNC Strategic Provider Relationships consultant if you have additional questions.