Vision as an Essential Health Benefit – A Review for Nurses and Educators

by | Jan 22, 2014 | Featured, News

A Milestone Expansion of Access to Pediatric Vision Care

 On January 1st, 2014 over 70 million children became eligible for a comprehensive eye examination and necessary treatment as one of the ten essential health benefits under the Affordable Care Act.


The U.S. Department of Health and Human Services has included routine pediatric vision care as one of the ten essential healthPediatric Vision Exam benefits. “The essential health benefits include ambulatory patient services; emergency care; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and rehabilitative services and devices; laboratory services; preventive and wellness services, and chronic disease management; and pediatric services, including dental and vision care. Plans in the individual and small-group markets both inside and outside of health care exchanges must cover essential health benefits beginning in 2014”.

Vision disorders are the the fourth most common disability in the United States and are one of the most prevalent handicapping conditions during childhood. An analysis of over one thousand infants seen across the country in 2006 showed that 17% of infants have a positive risk of an ocular or visual complication that requires careful follow up or immediate treatment. This risk increases to 25% if the child is premature, a minority, or the family income falls below $41,000 a year.  Many of these conditions have no identifiable signs or symptoms and can only be identified by a comprehensive vision and eye examination.

Visual development is dramatic between 6 and 12 months of age and is critical for a child’s normal overall development. Although most babies will develop normally if left alone, early detection and treatment of potential eye and vision problems can be key in setting the baby on the right track for development further in life. A vision problem can lead to difficulties in development, school, social interaction, and potential permanent vision loss.

A large component of education in school is achieved through reading after third grade and if a child has difficulty reading it can devastate their learning. Vision screenings alone  miss many potentially harmful conditions which are much harder to treat as the child grows older. A comprehensive eye and vision examination performed by a properly trained optometrist includes quantitative evaluations and treatment if necessary for amblyopia (lazy eye), strabismus (cross eye), anisometropia (difference in vision between the eyes), high refractive error (nearsightedness, farsightedness, and astigmatism), accommodative disorders (focusing system), and ocular disease.

The American Optometric Association recommends infants be seen between 6 and 12 months for their first visit, which will now be a covered benefit. Not only is this a critical time for eye and vision development, but generally children at this age do not yet fear doctor visits and find the assessment painless and often enjoyable. Eye assessments for children are recommended at this early age to allow proper time to detect and treat developing vision problems. Three to four million babies are born each year in the United States. A significant number of treatable eye conditions such as amblyopia (2.5 to 4.5 percent), strabismus (4 to 5 percent), clinically significant hyperopia (3 to 6 percent), or total refractive errors (12 percent) will develop prior to age 5. If the child has a normal evaluation in their first year of life, it is recommended that they be seen for a comprehensive evaluation at age 3, before first grade, and every two years after that.

These examinations will also allow the eye care professional to review with the parents and the educators the issues of safety during leisure and sport activities and how to prevent devastating eye injuries that could affect them for the remainder of their life. The eye care professional will be able to utilize these early detection exams to assist the educators in delivering information to the parents and child on learning methods and reading skills that will enhance their early developmental years in school. The optometric physician will be able to be a strong assistant, supporter, and advocate to the needs of the educators to enhance the child’s entry into the school system and throughout the academic years.

Pediatric eye health care is now an “Essential Health Benefit,” and must be offered by all new health plans as a distinct benefit from traditional well child care.  Pediatric eye health care is defined as an annual comprehensive eye exam and treatment, including medical eye care. All new health plans – both inside and outside of state exchanges – are required to provide fully integrated coverage for pediatric eye health care and must recognize optometrists as providers of medical eye care. Vision plans, including all vision plans (i.e. VSP, Davis, Spectera, Eyemed, NVA….), are permitted to partner with health plans in the offering of fully integrated eye health care coverage inside and outside of state exchanges.

Eye doctors can work closely with parents and the school systems to identify children who may have ocular or visual issues which would lead to an academic and educational delay. By working together, we can decrease  modifiable barriers to achieving success in their lives.

To find an optometric physician in your area who performs comprehensive pediatric eye and vision examinations use our doctor locator tool, here!

Looking for more info on what to expect at a pediatric eye exam? Find it here:

Pediatric Eye Exams: What you need to know (Powerpoint)


Special thanks to Dr. Ken Daniels, contributing author