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A BILL TO BE ENTITLED
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AN ACT
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relating to vision care benefits, including participation of |
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optometrists and therapeutic optometrists in vision care or managed |
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care plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter D, Chapter 1451, Insurance Code, is |
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amended by adding Section 1451.1545 to read as follows: |
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Sec. 1451.1545. PARTICIPATION IN VISION CARE PLAN; EFFECT |
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ON OTHER PLANS. (a) In this section, "vision care plan" has the |
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meaning assigned by Section 1451.157(a). |
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(b) A vision care plan issuer must include on the issuer's |
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Internet website a method for a licensed optometrist or therapeutic |
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optometrist to submit an application for inclusion as a |
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participating provider in the plan. The application: |
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(1) may only require an applicant to provide: |
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(A) standardized information prescribed by rules |
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adopted under Section 1452.052 that is applicable to an optometrist |
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or therapeutic optometrist; or |
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(B) information specified on the Council for |
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Affordable Quality Healthcare credentialing application; and |
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(2) must impose the same application requirements on |
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each optometrist and therapeutic optometrist. |
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(c) A vision care plan issuer shall: |
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(1) not later than the 10th business day after the date |
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the issuer receives an application described by Subsection (b) that |
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meets the plan's application requirements, make available |
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electronically to the applicant a participating provider contract, |
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including applicable reimbursement fee schedules, provider |
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handbooks, and provider manuals; |
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(2) not later than the 30th business day after the date |
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the issuer receives an application described by Subsection (b), |
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complete the credentialing determination and: |
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(A) approve the application and deliver to the |
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applicant a contract described by Subdivision (1) for acceptance |
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and signature by the approved applicant; or |
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(B) deny the application and, not later than the |
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10th business day after the date of the denial, deliver to the |
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applicant a written explanation of the issuer's decision; and |
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(3) not later than the 20th business day after the date |
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an approved applicant is credentialed and accepts the contract |
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delivered under Subdivision (2)(A), include the credentialed and |
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approved applicant as a participating provider in the plan. |
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(d) A vision care plan issuer: |
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(1) may only consider information included in an |
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optometrist's or therapeutic optometrist's credentialing |
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application in making a credentialing determination; and |
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(2) shall impose the same credentialing requirements |
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on each applicant optometrist or therapeutic optometrist. |
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(e) A vision care plan issuer must allow an optometrist or |
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therapeutic optometrist to be a participating provider to the full |
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extent of the optometrist's or therapeutic optometrist's license on |
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all of the issuer's: |
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(1) vision care plans that have enrollees located in |
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this state; and |
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(2) vision panels, as defined by Section 1451.154. |
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(f) Subsection (e) may not be construed to require a vision |
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plan issuer to cover a particular covered product or service as |
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defined by Section 1451.155. |
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(g) A vision care plan issuer may not exclude an optometrist |
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or a therapeutic optometrist as a participating provider in the |
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plan because of: |
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(1) the aggregate number of optometrists or |
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therapeutic optometrists on a vision panel as defined by Section |
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1451.154, including the aggregate number of optometrists or |
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therapeutic optometrists on a vision panel in a geographic service |
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area; or |
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(2) the time, distance, and appointment availability |
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for a patient to access a participating practitioner. |
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SECTION 2. Section 1451.155, Insurance Code, is amended by |
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adding Subsection (i) to read as follows: |
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(i) A contract between a managed care plan and an |
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optometrist or therapeutic optometrist must: |
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(1) include electronic access to a fee schedule that |
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includes and individually identifies each medical or vision care |
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product or service covered under the plan; and |
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(2) use the standardized codes, names, and definitions |
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described by Section 1451.153 to describe all reimbursable medical |
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or vision care products or services covered under the plan. |
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SECTION 3. Section 1451.157, Insurance Code, is amended to |
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read as follows: |
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Sec. 1451.157. VISION PLAN CONDUCT [EXTRAPOLATION |
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PROHIBITED]. (a) In this section: |
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(1) "Extrapolation" means a mathematical process or |
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technique used by a vision care plan in the audit of an optometrist |
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or therapeutic optometrist to estimate audit results or findings |
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for a larger batch or group of claims not reviewed by the plan. |
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(2) "Vision care plan" means a limited-scope policy, |
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agreement, contract, or evidence of coverage that provides coverage |
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for eye care expenses but does not provide comprehensive medical |
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coverage. |
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(b) A vision care plan shall [may] not: |
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(1) use extrapolation to complete an audit of a |
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participating optometrist or therapeutic optometrist. Any |
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additional payment due to a participating optometrist or |
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therapeutic optometrist or any refund due to the vision care plan |
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must be based on the actual overpayment or underpayment and may not |
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be based on an extrapolation; or |
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(2) exclude an optometrist or a therapeutic |
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optometrist as a participating practitioner in the plan if the |
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optometrist or therapeutic optometrist satisfies the vision plan's |
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credentialing requirements and agrees to the vision plan's |
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contractual terms. |
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(c) A vision care plan shall describe all medical or vision |
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care products or services covered under the plan using only the |
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standardized codes, names, and definitions published in the |
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Healthcare Common Procedure Coding System, including: |
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(1) Level I codes published by the American Medical |
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Association; and |
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(2) Level II codes published by the Centers for |
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Medicare and Medicaid Services. |
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SECTION 4. Subchapter D, Chapter 1451, Insurance Code, as |
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amended by this Act, applies only to a contract between a vision |
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care plan issuer and an optometrist or therapeutic optometrist |
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entered into or renewed on or after the effective date of this Act. |
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SECTION 5. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2025. |
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