This chapter shall be known and may be cited as the "Access to Eye Care Act."
(1) COVERED PERSON. Any individual, family, or family member on whose behalf third-party payment or prepayment of health or medical expenses is provided under an insurance policy, plan, or contract providing for third-party payment or prepayment of health care or medical expenses.
(2) EYE CARE PROVIDER. A licensed optometrist or a licensed ophthalmologist.
(3) INSURANCE POLICY, PLAN, OR CONTRACT PROVIDING FOR THIRD-PARTY PAYMENT OR PREPAYMENT OF HEALTH OR MEDICAL EXPENSES. Includes an individual or group policy for accident or health insurance, an individual or group hospital or health care service contract, an individual or group health maintenance organization contract, an organized delivery system contract, or a preferred provider organization contract, and any other similar policy, plan, or contract. This term shall not include any employee welfare benefit plan, as defined in 29 U.S.C. Section 1002(1), or any plan administered by a third party to the extent it provides services to an employee welfare benefit plan, as defined in 29 U.S.C. Section 1002(1).
An insurance policy, plan, or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment to a licensed optometrist for each service which falls within the scope of the optometrist's license, if the policy, plan, or contract pays for the same service when provided by any other provider for such services.
(1) Impose a practice restriction for optometrists which is inconsistent with or more restrictive than provided by law.
(2) Discriminate between classes of eye care providers with respect to any covered service which falls within the scope of the eye care provider's license.
(3) Require an eye care provider to hold hospital privileges as a condition of participation in or receiving payment from the policy, plan, or contract.
(4) Impose any restriction not required by law based on the eye care provider's professional degree.
(5) Discriminate between eye care providers in connection with the amount of reimbursement for the provision of the same services.
(6) Require an eye care provider to purchase or maintain a minimum quantity or minimum dollar amount of a specified brand of ophthalmic materials as a condition of participation in or receiving payments from a policy, plan, or contract.
a. Medical treatment of glaucoma.
(2) Ensures that any list of medical or health care providers participating in, or otherwise eligible to provide services under, the policy, plan, or contract includes eye care providers to the same extent that such list includes other medical or health care providers to whom a covered person has direct access, without need for referral or preapproval, under the policy, plan, or contract.
(b) An insurance policy, plan, or contract providing for third-party payment or prepayment of health or medical expenses shall not deny or limit reimbursement to any covered person on the ground that the covered person was not referred to the eye care provider by a person acting on behalf of, or under an agreement with, the company, entity, or person providing the insurance policy, plan, or contract.
This chapter shall apply to services provided under a policy, plan, or contract providing for third-party payment or prepayment of health or medical expenses delivered, continued, or renewed in this state on or after August 1, 2001, and to any such existing policy, plan, or contract, on its anniversary or renewal date, or upon the expiration of the applicable collective bargaining contract, if any, whichever is later.
(a) This chapter does not require and shall not be construed to require any insurance policy, plan, or contract to provide health care coverage for eye care. The provisions of this chapter are applicable only to those insurance policies, plans, or contracts which provide coverage for eye care.
(b) Insurers or other issuers of any insurance policy, plan, or contract which provides coverage for eye care shall continue to be able to establish and apply selection criteria and utilization protocols for health care providers as well as credentialing criteria used in the selection of providers.
(c) This chapter does not require and shall not be construed to require the coverage of eye care services by providers who are not designated as covered providers, or who are not selected as participating providers, by an insurance policy, plan, or contract, or the issuer thereof having a participating network of service providers. Provided, however, if eye care coverage is provided, reasonable efforts shall be made to include a sufficient number of qualified providers, including optometrists, to insure reasonable access to eye care services.
(a) Any insurance policy, plan, or contract that provides coverage for eye care services may contain provisions for maximum benefits and coinsurance limitations, deductibles, exclusions, and utilization review protocols to the extent that these provisions are not inconsistent with the requirements of this chapter.
(b) If eye care coverage is provided, the eye care benefits for services provided by optometrists within the scope of their licenses shall be subject to the same annual deductible or coinsurance established for all other eye care providers for which coverage is provided.
Nothing in this chapter shall be construed to expand the scope of practice for any eye care provider.