Spectera and Healthcare Reform

Although the changes haven’t happened yet, more patients with UnitedHealthCare medical plans will receive eye care from Spectera Eyecare Network’s providers.

  • New coverage mandated by the Affordable Care Act (ACA) includes an annual eye exam and eyewear for pediatric patients.  These patients will be directed to Spectera Eye care networks and you must be a contracted provider to offer this benefit.  TSO is a contracted provider network for this program.
  • Because the ACA requires all essential health benefits to be offered without annual or lifetime dollar limits (allowances), pediatric vision will be covered with a variety of cost-sharing designs, including copays and coinsurance.  Some vision benefits may apply to plan deductibles and out-of-pocket maximums.  The new pediatric vision benefit is included in medical plans, rather than standalone vision plans.
  • Typical pediatric vision benefits in medical plans will include a comprehensive eye exam; a pair of eyeglasses (frame and polycarb lenses); and formulary contact lenses in lieu of eyeglasses annually.
  • UnitedHealthCare plans with pediatric vision coverage will not limit patients to a frame or lens formulary.  Patients can choose any frames offered in your office.  Patients will pay U&C after allowance. 

You must include all appropriate diagnosis codes on your claims in order to accurately represent both medical and routine eye care encounters.  The reason for the patient’s visit is a criterion for eye care coverage and clams payment.  For examination coding clarification, please visit unitedhealthcareupdate.com.