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One of New Mexico’s largest and best-known health insurers has called off plans to dissolve its optometric provider network and “carve out” vision care coverage, after determining the action could have effectively left thousands of state residents without adequate access to medical eye care, according to the New Mexico Optometric Association (NMOA).

In restoring its OD network for comprehensive eye care, top officials of the Albuquerque-based Lovelace Health Plan acknowledged they did not fully understand the contemporary scope of optometric practice or just how many of their 197,000 beneficiaries today rely primarily on optometrists for eye care, according to NMOA Legislative Chair Bobby Jarrell, O.D.

“They were still of the belief that optometrists provided basically eyeglasses and contact lenses and that medical eye care was provided mostly by ophthalmologists,” Dr. Jarrell said, following successful talks between NMOA and the insurer late last year.

The negotiations – which resulted in the health plan re-establishing its optometry network less than 30 days after moving to dissolve it – were typical of what AOA Third Party Center Director Maureen West believes will be increasingly common discussions between optometrists and state or regional health plans regarding coverage of eye care services.

Most of the nation’s largest public and private health insurers, including many employer-based plans, now cover eye health services provided in optometric practices, West noted. She credits today’s acceptance of optometric medical eye care among major health plans to an extensive AOA insurance industry education campaign that over the past two decades has gained 44 million Americans access to covered eye care services in optometric practices.

However, managers at many local and regional health plans still may not understand the role optometrists now play in eye health, West said. 

Lovelace – a highly respected New Mexico institution and the state’s third-largest insurer – stunned its 40 to 50 contracted panel optometrists in late November with notification that it was terminating their service agreements and shifting all eye and vision care coverage to a specialized vision insurer. Beneficiaries would henceforth receive only vision examinations and eyewear through the vision plan’s provider panel, and all medical eye care would be provided through Lovelace’s panel of ophthalmologists.

The change was essentially a cost-cutting move designed to save administrative expenses for vision care, company officials later told the NMOA.

However, the separation of Lovelace’s vision plan from its medical plan effectively removed optometrists as a medical eye care option.

And in New Mexico, where optometrists are the only source of eye care in most counties and with ophthalmologists found mostly in a few large cities, that could have posed a real access problem for many residents, Dr. Jarrell said.

Unlike neighboring Texas, New Mexico does not require managed care plans to accept all therapeutically certified optometrists on their vision provider panels as members of their medical eye care panels.

NMOA President Mamie C. Chan, O.D., Third Party Chair Dwight Thibodeaux, O.D., Executive Director Richard Montoya, and Dr. Jarrell quickly scheduled an early December meeting at the health plan’s headquarters, as soon as they learned of Lovelace’s plan to limit eye care by optometrists.

During the meeting, Lovelace executives – who were well aware that there is a high level of demand for medical eye care in New Mexico – were surprised to learn that optometrists had become major providers of that care.

New Mexico has large Hispanic and Native American populations – with higher than average incidences of many eye and systemic health problems as well as lower than average treatment rates, according to government health disparity studies. The Navajo Nation, which comprises much of New Mexico’s Native American population, has the highest incidence of diabetes in America. A substantial older adult population and the state’s often harsh environment also contribute to demand for medical eye care, Dr. Jarrell noted.

To help address that demand, the New Mexico legislature has authorized a broad scope of optometric practice, including some surgery. The state’s optometrists have become highly important in surgical co-management, authorized under law to see cataract patients one day after surgery, Dr. Jarrell said.

That can be important in a heavily rural state where much of the population lives in small communities that may be separated from the surgeons in larger cities by miles of mountain range or open desert, Dr. Jarrell noted.

The Lovelace Health Plan is part of a highly respected New Mexico institution, established in 1880 by missionaries and philanthropists to increase access to quality health care in the region. It has consistently demonstrated a commitment to health care access among the underserved, Dr. Jarrell noted.

The talks between the NMOA and the plan on maintaining access to eye care “were not at all confrontational,” Dr. Jarrell reports. “The focus remained strictly on the patients. We said, ‘Look, you have a good (insurance) product here. You have promised this access to care. We want to help you maintain the quality of your product.’”

By late December, Lovelace had notified its panel optometrists that it was rescinding its decision to terminate their service agreements. Lovelace may still contract with the vision plan to provide some administrative services, Dr. Jarrell said.

Prior to their meeting with Lovelace officials, NMOA representatives consulted with the AOA Third Party Center for guidance on insurance company negotiations.

Under a new initiative, the AOA Third Party Center urges state optometric associations, local optometric societies, and even individual practitioners to assess the policies of area insurers and schedule meetings with plans that do not fully cover eye health services provided in optometric practices.

To assist, the center offers packaged presentations and materials originally developed for use in negotiations with major national health plans.

In addition to consulting with the AOA Third Party Center, Dr. Jarrell advises optometrists to check with the AOA State Government Relations Center, for a briefing on pertinent state law, before meeting with insurance plans on coverage of medical eye care.

He also urges optometrists to “practice to the scope authorized. Treat eye care as eye care, code it correctly and charge appropriately for it. That way, if you are called on to document the volume of medical eye care you are providing, the data will be there in insurance plan records to prove it.”