89R21809 SCF-F

By: Dean, Gerdes H.B. No. 3211

Substitute the following for H.B. No. 3211:

By: Dean C.S.H.B. No. 3211

A BILL TO BE ENTITLED

AN ACT

relating to the participation of optometrists and therapeutic optometrists in managed care plans providing vision benefits.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Sections 1451.153(a) and (b), Insurance Code, are amended to read as follows:

(a) A managed care plan may not:

(1) discriminate against a health care practitioner because the practitioner is an optometrist or a therapeutic optometrist;

(2) restrict or discourage a plan participant from obtaining covered vision or medical eye care services or procedures from a participating optometrist or therapeutic optometrist solely because the practitioner is an optometrist or therapeutic optometrist;

(3) exclude an optometrist or a therapeutic optometrist as a participating practitioner in the plan because the optometrist or therapeutic optometrist does not have medical staff privileges at a hospital or at a particular hospital;

(4) identify a participating optometrist or therapeutic optometrist differently from another optometrist or therapeutic optometrist based on:

(A) a discount or incentive offered on a medical or vision care product or service, as defined by Section 1451.155, that is not a covered product or service, as defined by Section 1451.155, by the optometrist or therapeutic optometrist;

(B) the dollar amount, volume amount, or percent usage amount of any product or good purchased by the optometrist or therapeutic optometrist; or

(C) the brand, source, manufacturer, or supplier of a medical or vision care product or service, as defined by Section 1451.155, utilized by the optometrist or therapeutic optometrist to practice optometry;

(5) incentivize, recommend, encourage, persuade, or attempt to persuade an enrollee to obtain covered or uncovered products or services:

(A) at any particular participating optometrist or therapeutic optometrist instead of another participating optometrist or therapeutic optometrist;

(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 or therapeutic optometrist; 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 or therapeutic optometrist;

(6) exclude an optometrist or a therapeutic optometrist as a participating practitioner in the plan because the services or procedures provided by the optometrist or therapeutic optometrist may be provided by another type of health care practitioner; [or]

(7) as a condition for a therapeutic optometrist to be included in one or more of the plan's medical panels, require the therapeutic optometrist to be included in, or to accept the terms of payment under or for, a particular vision panel in which the therapeutic optometrist does not otherwise wish to be included; or

(8) exclude an optometrist or a therapeutic optometrist as a participating practitioner in the plan if the optometrist or therapeutic optometrist satisfies the plan's credentialing requirements and agrees to the plan's contractual terms.

(b) A managed care plan shall:

(1) include optometrists and therapeutic optometrists as participating health care practitioners in the plan;

(2) include the name of a participating optometrist or therapeutic optometrist in any list of participating health care practitioners and give equal prominence to each name;

(3) provide directly to an optometrist, therapeutic optometrist, 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 or a therapeutic optometrist 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 and that allows the optometrist or therapeutic optometrist to submit details for both services and vision care products to facilitate the authorization, submission, and reimbursement of claims; [and]

(6) describe all reimbursable medical or vision care products or services covered under the plan using the standardized codes, names, and definitions published in the Healthcare Common Procedure Coding System, including:

(A) Level I codes published by the American Medical Association; and

(B) Level II codes published by the Centers for Medicare and Medicaid Services; and

(7) allow an optometrist or a therapeutic optometrist to receive reimbursement through an electronic funds transfer.

SECTION 2. Subchapter D, Chapter 1451, Insurance Code, is amended by adding Section 1451.1545 to read as follows:

Sec. 1451.1545. PARTICIPATION IN VISION CARE PLAN; EFFECT ON OTHER PLANS. (a) In this section, "vision care plan" has the meaning assigned by Section 1451.157(a).

(b) A vision care plan issuer must include on the issuer's Internet website a method for a licensed optometrist or therapeutic optometrist to submit an application for inclusion as a participating provider in the plan. The application:

(1) may only require an applicant to provide:

(A) standardized information prescribed by rules adopted under Section 1452.052 that is applicable to an optometrist or therapeutic optometrist; or

(B) information specified on the Council for Affordable Quality Healthcare credentialing application; and

(2) must impose the same application requirements on each optometrist and therapeutic optometrist.

(c) A vision care plan issuer shall:

(1) not later than the 10th business day after the date the issuer receives an application described by Subsection (b) that meets the plan's application requirements, electronically deliver to the applicant a participating provider contract, including applicable reimbursement fee schedules, provider handbooks, and provider manuals;

(2) not later than the 30th business day after the date the issuer receives an application described by Subsection (b), complete the credentialing determination and:

(A) approve the application and deliver to the applicant a contract described by Subdivision (1) for acceptance and signature by the approved applicant; or

(B) deny the application and, not later than the 10th business day after the date of the denial, deliver to the applicant a written explanation of the issuer's decision; and

(3) not later than the 20th business day after the date an approved applicant accepts the contract delivered under Subdivision (2)(A), include the credentialed and approved applicant as a participating provider in the plan.

(d) A vision care plan issuer:

(1) may only consider information included in an optometrist's or therapeutic optometrist's credentialing application in making a credentialing determination; and

(2) shall impose the same credentialing requirements on each applicant optometrist or therapeutic optometrist.

(e) A vision care plan issuer must allow an optometrist or therapeutic optometrist to be a participating provider to the full extent of the optometrist's or therapeutic optometrist's license on all of the issuer's:

(1) vision care plans and other managed care plans with vision benefits that have enrollees located in this state; and

(2) vision panels, as defined by Section 1451.154.

(f) Subsection (e) may not be construed to require a vision plan issuer to contract with an optometrist or a therapeutic optometrist for a particular covered product or service as defined by Section 1451.155.

(g) A vision care plan issuer may not exclude an optometrist or a therapeutic optometrist as a participating provider in the plan because of:

(1) the aggregate number of optometrists or therapeutic optometrists on a vision panel as defined by Section 1451.154, including the aggregate number of optometrists or therapeutic optometrists on a vision panel in a geographic service area; or

(2) the time, distance, and appointment availability for a patient to access a participating practitioner.

SECTION 3. Section 1451.155, Insurance Code, is amended by adding Subsection (i) to read as follows:

(i) A contract between a managed care plan and an optometrist or therapeutic optometrist must:

(1) include a fee schedule that includes and individually identifies each medical or vision care product or service covered under the plan; and

(2) use the standardized codes, names, and definitions described by Section 1451.153 to describe all reimbursable medical or vision care products or services covered under the plan.

SECTION 4. Section 1451.157(a)(2), Insurance Code, is amended to read as follows:

(2) "Vision care plan" means a managed care plan that:

(A) is offered in the form of a limited-scope policy, agreement, contract, or evidence of coverage; and

(B) [that] provides coverage for eye care expenses but does not provide comprehensive medical coverage.

SECTION 5. The changes in law made by this Act apply only to a contract between a vision care plan issuer and an optometrist or therapeutic optometrist entered into or renewed on or after the effective date of this Act.

SECTION 6. This Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Section 39, Article III, Texas Constitution. If this Act does not receive the vote necessary for immediate effect, this Act takes effect September 1, 2025.