88R8785 CJD-F
 
  By: Buckley H.B. No. 1696
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the relationship between managed care plans and
  optometrists, therapeutic optometrists, and ophthalmologists.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1451.151(1), Insurance Code, is amended
  to read as follows:
               (1)  "Managed care plan" means a plan under which a
  health maintenance organization, preferred provider benefit plan
  issuer, vision benefit plan issuer, vision benefit plan
  administrator, or other organization provides or arranges for
  health care benefits or vision benefits to plan participants and
  requires or encourages plan participants to use health care
  practitioners the plan designates.
         SECTION 2.  Section 1451.153, Insurance Code, is amended to
  read as follows:
         Sec. 1451.153.  USE OF OPTOMETRIST, THERAPEUTIC
  OPTOMETRIST, OR OPHTHALMOLOGIST.  (a)  A managed care plan may not:
               (1)  discriminate against a health care practitioner
  because the practitioner is an optometrist, therapeutic
  optometrist, or ophthalmologist;
               (2)  restrict or discourage a plan participant from
  obtaining covered vision or medical eye care services or procedures
  from a participating optometrist, therapeutic optometrist, or
  ophthalmologist solely because the practitioner is an optometrist,
  therapeutic optometrist, or ophthalmologist;
               (3)  exclude an optometrist, therapeutic optometrist,
  or ophthalmologist as a participating practitioner in the plan
  because the optometrist, therapeutic optometrist, or
  ophthalmologist does not have medical staff privileges at a
  hospital or at a particular hospital;
               (4)  deny participation of an optometrist, therapeutic
  optometrist, or ophthalmologist as a participating practitioner in
  the plan if the optometrist, therapeutic optometrist, or
  ophthalmologist meets the plan's credentialing requirements and
  agrees to the plan's contractual terms;
               (5)  create, offer, or use a contractual fee schedule
  that reimburses an optometrist, therapeutic optometrist, or
  ophthalmologist differently from another optometrist, therapeutic
  optometrist, or ophthalmologist based on professional degree held;
               (6)  identify a participating optometrist, therapeutic
  optometrist, or ophthalmologist differently from other
  participating health care practitioners based on any
  characteristic other than professional degree held;
               (7)  incentivize, recommend, encourage, persuade, or
  attempt to persuade an enrollee to obtain covered or uncovered
  products or services:
                     (A)  at any particular participating optometrist,
  therapeutic optometrist, or ophthalmologist instead of another
  participating optometrist, therapeutic optometrist, or
  ophthalmologist;
                     (B)  at a retail establishment owned by, partially
  owned by, contracted with, or otherwise affiliated with the managed
  care plan instead of a different participating optometrist,
  therapeutic optometrist, or ophthalmologist; or
                     (C)  at any Internet or virtual provider or
  retailer owned by, partially owned by, contracted with, or
  otherwise affiliated with the managed care plan instead of a
  different participating optometrist, therapeutic optometrist, or
  ophthalmologist;
               (8)  exclude an optometrist, therapeutic optometrist,
  or ophthalmologist as a participating practitioner in the plan
  because the services or procedures provided by the optometrist,
  therapeutic optometrist, or ophthalmologist may be provided by
  another type of health care practitioner; or
               (9) [(5)]  as a condition for a therapeutic optometrist
  or ophthalmologist to be included in one or more of the plan's
  medical panels, require the therapeutic optometrist or
  ophthalmologist to be included in, or to accept the terms of payment
  under or for, a particular vision panel in which the therapeutic
  optometrist or ophthalmologist does not otherwise wish to be
  included.
         (b)  A managed care plan shall:
               (1)  include optometrists, therapeutic optometrists,
  and ophthalmologists as participating health care practitioners in
  the plan; [and]
               (2)  include the name of a participating optometrist,
  therapeutic optometrist, or ophthalmologist in any list of
  participating health care practitioners and give equal prominence
  to each name;
               (3)  provide directly to an optometrist, therapeutic
  optometrist, ophthalmologist, or plan enrollee immediate access by
  electronic means to an enrollee's complete plan coverage
  information, including in-network and out-of-network coverage
  details;
               (4)  publish complete plan information, including
  in-network and out-of-network coverage details, with any marketing
  materials that describe the plan benefits, including any summary
  plan description;
               (5)  allow an optometrist, therapeutic optometrist, or
  ophthalmologist to utilize any third-party claim-filing service,
  billing service, or electronic data interchange clearinghouse
  company that uses the standardized claim submission protocol of the
  National Uniform Claim Committee to facilitate the authorization,
  submission, and reimbursement of claims; and
               (6)  allow an optometrist, therapeutic optometrist, or
  ophthalmologist to receive reimbursement through an automated
  clearinghouse electronic funds transfer.
         (c)  For the purposes of Subsection (a)(9) [(a)(5)],
  "medical panel" and "vision panel" have the meanings assigned by
  Section 1451.154(a).
         SECTION 3.  Section 1451.154(c), Insurance Code, is amended
  to read as follows:
         (c)  A therapeutic optometrist who is included in a managed
  care plan's medical panels under Subsection (b) must:
               (1)  abide by the terms and conditions of the managed
  care plan;
               (2)  satisfy the managed care plan's credentialing
  standards for therapeutic optometrists; and
               (3)  provide proof that the Texas Optometry Board
  considers the therapeutic optometrist's license to practice
  therapeutic optometry to be in good standing[; and
               [(4)  comply with the requirements of the Controlled
  Substances Registration Program operated by the Department of
  Public Safety].
         SECTION 4.  Section 1451.155, Insurance Code, is amended to
  read as follows:
         Sec. 1451.155.  CONTRACTS WITH OPTOMETRISTS OR THERAPEUTIC
  OPTOMETRISTS.  (a)  In this section:
               (1)  "Chargeback" means a dollar amount, fee,
  surcharge, or item of value that reduces, modifies, or offsets all
  or part of the patient responsibility, provider reimbursement, or
  fee schedule for a covered product or service.
               (2)  "Covered product or service" means a medical or
  vision care product or service for which reimbursement is available
  under an enrollee's managed care plan contract or for which
  reimbursement is available subject to a contractual limitation,
  including:
                     (A)  a deductible;
                     (B)  a copayment;
                     (C)  coinsurance;
                     (D)  a waiting period;
                     (E)  an annual or lifetime maximum limit;
                     (F)  a frequency limitation; or
                     (G)  an alternative benefit payment.
               (3) [(2)]  "Medical or vision [Vision] care product or
  service" means a product or service provided within the scope of the
  practice of optometry or therapeutic optometry under Chapter 351,
  Occupations Code.
         (a-1)  For the purposes of this section, a product or service
  reimbursed to an optometrist or therapeutic optometrist at a
  nominal or de minimis rate is not a covered product or service.
         (a-2)  For the purposes of this section, a product or service
  reimbursed to an optometrist or therapeutic optometrist solely by
  the enrollee is not a covered product or service.
         (b)  A contract between a managed care plan [an insurer] and
  an optometrist or therapeutic optometrist may not limit the fee the
  optometrist or therapeutic optometrist may charge for a product or
  service that is not a covered product or service.
         (c)  A contract between a managed care plan [an insurer] and
  an optometrist or therapeutic optometrist may not require a
  discount on a product or service that is not a covered product or
  service.
         (d)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  authorizing a chargeback to the patient, optometrist, or
  therapeutic optometrist if the chargeback is for a covered product
  or service that the managed care plan does not produce, deliver, or
  provide.
         (e)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  authorizing a reimbursement fee schedule for a covered product or
  service that is different from the fee schedule applicable to
  another optometrist or therapeutic optometrist because of the
  optometrist's or therapeutic optometrist's choice of:
               (1)  optical laboratory;
               (2)  source or supplier of:
                     (A)  contact lenses;
                     (B)  ophthalmic lenses;
                     (C)  ophthalmic glasses frames; or
                     (D)  covered or uncovered products or services;
               (3)  equipment used for patient care;
               (4)  retail optical affiliation;
               (5)  vision support organization;
               (6)  group purchasing organization;
               (7)  doctor alliance;
               (8)  professional trade association membership;
               (9)  affiliation with an arrangement defined as a
  franchise by 16 C.F.R. Part 436;
               (10)  electronic health record software, electronic
  medical record software, or practice management software; or
               (11)  third-party claim-filing service, billing
  service, or electronic data interchange clearinghouse company.
         (f)  A managed care plan may not change a contract between a
  managed care plan and an optometrist or therapeutic optometrist,
  including terms, reimbursements, or fee schedules, unless:
               (1)  the managed care plan provides written notice of
  the change to the optometrist or therapeutic optometrist at least
  90 days before the date the proposed change takes effect; and
               (2)  the optometrist or therapeutic optometrist
  affirmatively agrees in writing to the change.
         (g)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  requiring a patient, optometrist, or therapeutic optometrist to
  obtain precertification or prior authorization for a covered
  product or service provided by the optometrist or therapeutic
  optometrist.
         (h)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  requiring the optometrist or therapeutic optometrist to provide a
  covered product or service at a loss.
         (i)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  requiring the optometrist or therapeutic optometrist to accept a
  reimbursement payment in the form of a virtual credit card or any
  other payment method where a processing fee, administrative fee,
  percentage amount, or dollar amount is assessed to receive the
  reimbursement payment, except in the case of a nominal fee assessed
  by the optometrist's or therapeutic optometrist's bank to receive
  an electronic funds transfer.
         SECTION 5.  The heading to Section 1451.156, Insurance Code,
  is amended to read as follows:
         Sec. 1451.156.  CERTAIN CONDUCT PROHIBITED [CONDUCT].
         SECTION 6.  Section 1451.156(a), Insurance Code, is amended
  to read as follows:
         (a)  A managed care plan, as described by Section
  1451.152(a), may not directly or indirectly:
               (1)  control or attempt to control the professional
  judgment, manner of practice, or practice of an optometrist or
  therapeutic optometrist;
               (2)  employ an optometrist or therapeutic optometrist
  to provide a vision care product or service as defined by Section
  1451.155;
               (3)  pay an optometrist or therapeutic optometrist for
  a service not provided;
               (4)  reimburse an optometrist or therapeutic
  optometrist a different amount for a covered product or service as
  defined by Section 1451.155 because of the optometrist's or
  therapeutic optometrist's choice of:
                     (A)  optical laboratory;
                     (B)  source or supplier of:
                           (i)  contact lenses;
                           (ii)  ophthalmic lenses;
                           (iii)  ophthalmic glasses frames; or
                           (iv)  covered or uncovered products or
  services;
                     (C)  equipment used for patient care;
                     (D)  retail optical affiliation;
                     (E)  vision support organization;
                     (F)  group purchasing organization;
                     (G)  doctor alliance;
                     (H)  professional trade association membership;
                     (I)  affiliation with an arrangement defined as a
  franchise by 16 C.F.R. Part 436;
                     (J)  electronic health record software,
  electronic medical record software, or practice management
  software; or
                     (K)  third-party claim-filing service, billing
  service, or electronic data interchange clearinghouse company;
               (5)  restrict, [or] limit, or influence an
  optometrist's or therapeutic optometrist's choice of sources or
  suppliers of services or materials, including optical laboratories
  used by the optometrist or therapeutic optometrist to provide
  services or materials to a patient;
               (6)  restrict, limit, or influence an optometrist's or
  therapeutic optometrist's choice of electronic health record
  software, electronic medical record software, or practice
  management software;
               (7)  restrict, limit, or influence an optometrist's or
  therapeutic optometrist's choice of third-party claim-filing
  service, billing service, or electronic data interchange
  clearinghouse company;
               (8)  restrict or limit an optometrist's or therapeutic
  optometrist's access to a patient's complete plan coverage
  information, including in-network and out-of-network coverage
  details;
               (9)  apply a chargeback, as defined by Section
  1451.155, to a patient, optometrist, or therapeutic optometrist if
  the chargeback is for a covered product or service that the managed
  care plan does not produce, deliver, or provide;
               (10)  require an optometrist or therapeutic
  optometrist to provide a covered product at a loss; [or]
               (11) [(5)]  require an optometrist or therapeutic
  optometrist to disclose a patient's confidential or protected
  health information unless the disclosure is authorized by the
  patient or permitted without authorization under the Health
  Insurance Portability and Accountability Act of 1996 (42 U.S.C.
  Section 1320d et seq.) or under Section 602.053;
               (12)  require an optometrist or therapeutic
  optometrist to disclose or report a medical history or diagnosis as
  a condition to file a claim, adjudicate a claim, or receive
  reimbursement for a routine or wellness vision eye exam;
               (13)  require an optometrist or therapeutic
  optometrist to disclose or report a patient's glasses prescription,
  contact lens prescription, ophthalmic device measurements, facial
  photograph, or unique anatomical measurements as a condition to
  file a claim, adjudicate a claim, or receive reimbursement for a
  claim;
               (14)  require an optometrist or therapeutic
  optometrist to disclose any patient information, other than
  information identified on the version of the Health Insurance Claim
  Form approved by the National Uniform Claim Committee as of March 1,
  2023, as a condition to file a claim, adjudicate a claim, or receive
  reimbursement for a claim;
               (15)  require a patient, optometrist, or therapeutic
  optometrist to obtain precertification or prior authorization for a
  covered product or service provided by the optometrist or
  therapeutic optometrist;
               (16)  require an optometrist or therapeutic
  optometrist to provide a covered product or service at a loss; or
               (17)  require an optometrist or therapeutic
  optometrist to accept a reimbursement payment in the form of a
  virtual credit card or any other payment method where a processing
  fee, administrative fee, percentage amount, or dollar amount is
  assessed to receive the reimbursement payment, except in the case
  of a nominal fee assessed by the optometrist's or therapeutic
  optometrist's bank to receive an electronic funds transfer.
         SECTION 7.  Subchapter D, Chapter 1451, Insurance Code, is
  amended by adding Sections 1451.157 and 1451.158 to read as
  follows:
         Sec. 1451.157.  EXTRAPOLATION PROHIBITED. (a)  In this
  section, "extrapolation" means a mathematical process or technique
  used by a managed care plan in the audit of a participating
  physician or provider to estimate audit results or findings for a
  larger batch or group of claims not reviewed by the plan.
         (b)  A managed care plan may not use extrapolation to
  complete an audit of a participating optometrist or therapeutic
  optometrist.  Any additional payment due to a participating
  optometrist or therapeutic optometrist or any refund due to the
  managed care plan must be based on the actual overpayment or
  underpayment and may not be based on an extrapolation.
         Sec. 1451.158.  ENFORCEMENT OF SUBCHAPTER. (a)  A violation
  of this subchapter by a managed care plan is an unfair method of
  competition or an unfair or deceptive act or practice in the
  business of insurance under Chapter 541 and is subject to
  enforcement under that chapter.
         (b)  Notwithstanding Section 541.002, a managed care plan
  that provides vision benefits is considered a person for purposes
  of enforcing this subchapter under Chapter 541.
         SECTION 8.  Sections 1451.154(d) and 1451.156(d), Insurance
  Code, are repealed.
         SECTION 9.  The changes in law made by this Act apply only to
  a contract between a managed care plan and an optometrist,
  therapeutic optometrist, or ophthalmologist entered into or
  renewed, or a managed care plan delivered, issued for delivery, or
  renewed, on or after January 1, 2024.  A contract entered into or
  renewed, or a managed care plan delivered, issued for delivery, or
  renewed, before January 1, 2024, is governed by the law as it
  existed immediately before the effective date of this Act, and that
  law is continued in effect for that purpose.
         SECTION 10.  This Act takes effect September 1, 2023.