Bill Text: TX SB860 | 2023-2024 | 88th Legislature | Introduced
Bill Title: Relating to the relationship between managed care plans and optometrists, therapeutic optometrists, and ophthalmologists.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2023-03-01 - Referred to Health & Human Services [SB860 Detail]
Download: Texas-2023-SB860-Introduced.html
88R8785 CJD-F | ||
By: Hughes | S.B. No. 860 |
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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) [ |
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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; [ |
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(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) [ |
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"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[ |
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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) [ |
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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 [ |
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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 [ |
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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 [ |
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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, [ |
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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; [ |
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(11) [ |
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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. |