HOUSE DOCKET, NO. 895        FILED ON: 1/14/2015

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 920

The Commonwealth of Massachusetts

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PRESENTED BY:

David M. Nangle

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To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act relative to consumer choice of vision and eyecare services.

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PETITION OF:

HOUSE DOCKET, NO. 895        FILED ON: 1/14/2015

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 920

The Commonwealth of Massachusetts

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In the One Hundred and Eighty-Ninth General Court
(2015-2016)

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An Act relative to consumer choice of vision and eyecare services.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1. Chapter 175, as appearing in the 2014 Official Edition, shall be amended by inserting the following new section-:

Section 193V.  Consumer Choice of Vision and Eyecare Services.

(a)For purposes of this section the following terms shall have the following meanings:

“Carrier”, an insurer licensed or otherwise authorized to transact accident or health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; an optometric services corporation organized under chapter 176F; a health maintenance organization organized under chapter 176G; an organization entering into a preferred provider arrangement under chapter 176I; a contributory group general or blanket insurance for persons in the service of the commonwealth under chapter 32A; a contributory group general or blanket insurance for persons in the service of counties, cities, towns and districts, and their dependents under chapter 32B; the medical assistance program administered by the division of medical assistance pursuant to chapter 118E and in accordance with Title XIX of the Social Security Act or any successor statute; and any other medical assistance program operated by a governmental unit for persons categorically eligible for such program.

“Covered services”, vision and eyecare services and materials for which reimbursement from a vision plan or  health insurance plan is provided by a member’s or subscriber’s plan contract, or for which a reimbursement would be available but for application of the deductible, co-payment, or coinsurance requirements under the member’s or subscriber’s health insurance plan.

“Health insurance plan”, any health insurance policy or health benefit plan offered by a carrier, health insurer or a subcontractor of a health insurer, as well as Medicaid and any other public health care assistance program offered or administered by the Commonwealth or by any subdivision or instrumentality of the Commonwealth. This term includes vision plans, regardless of whether stand-alone or limited in scope, but does not include policies or plans providing coverage for a specified disease or other limited benefit coverage.

“Materials” includes lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.

“Ophthalmologist” means a person licensed pursuant to Section 2 of Chapter 112 who has completed specialized training in the field of ophthalmology. 

“Optometrist” means a person licensed pursuant to Section 68 of Chapter 112.

(b)To the extent a health insurance plan provides coverage for vision care or health care services, it shall cover those services whether provided by a licensed optometrist or by a licensed ophthalmologist, provided the health care provider is acting within his or her authorized scope of practice and participates in the plan’s network.

(c)A health insurance plan shall impose no greater co-payment, coinsurance, or other cost-sharing amount for services when provided by an optometrist than for the same service when provided by an ophthalmologist.

(d)A health insurance plan shall provide to a licensed health care provider acting within his or her scope of practice the same level of reimbursement or other compensation for providing vision care and health care services that are within the lawful scope of practice of the professions of medicine and optometry, regardless of whether the health care provider is an optometrist or an ophthalmologist.

(e)(1) A carrier, health insurer, third party administrator, entity that writes vision or health insurance, or entity that manages a vision or health insurance plan for a carrier or health insurer shall permit a licensed optometrist to participate in plans or contracts providing for vision care or health care services to the same extent as it does an ophthalmologist, regardless of whether such plan is a plan of insurance or vision care discount program that is not an insurance plan. (2) A carrier, health insurer, third party administrator, entity that writes vision or health insurance, or entity that manages a vision and/or health insurance plan for a carrier or health insurer shall not require a licensed optometrist or ophthalmologist to provide discounted materials or benefits, nor shall a carrier require a licensed optometrist or ophthalmologist to participate as a provider in another vision or health insurance plan or contract as a condition or requirement for the optometrist’s or ophthalmologist’s participation as a provider in any health or vision care plan or contract. (3) A carrier, health insurer, third party administrator, entity that writes vision or health insurance, or entity that manages a vision and/or health insurance plan for an insurer shall not refuse to allow an optometrist or ophthalmologist to continue to provide covered services through its health insurance plans and other product lines when the provider opts out of a particular product line.

(f)(1) An agreement between a carrier, health insurer, third party administrator, entity that writes vision or health insurance, or entity that manages a vision or health insurance plan for a carrier or insurer, and an optometrist or ophthalmologist for the provision of vision or health care services to plan members or subscribers in connection with coverage under a stand-alone vision or  eyecare plan or other health insurance plan shall not require that an optometrist or ophthalmologist provide services or materials at a fee limited or set by the plan, carrier or insurer unless the services or materials are reimbursed as covered services under the contract. (2) An optometrist or ophthalmologist shall not charge more for services and materials that are non-covered services under a vision or health insurance plan than his or her usual and customary rate for those services and materials. (3) Reimbursement paid by a vision or health insurance plan for covered services and materials shall be reasonable and shall not provide nominal reimbursement in order to claim that services and materials are covered services. (4) For all commercially insured plans, the covered services under any vision or health insurance plan shall not limit, directly or indirectly, the choice of sources and suppliers of materials by a patient of a vision or health care provider.

(g)No carrier, health insurer, third party administrator, entity that writes vision or health insurance, or entity that manages a vision or health insurance plan for a carrier or insurer shall change the terms, discounts or rates provided under a vision or health insurance plan, policy or discount program that is not an insurance plan, without first obtaining the health care provider’s concurrence and agreement to such change.

(h)If the insured has more than one vision or health insurance plan that provides coverage for vision or health care services, the provider rendering such service may submit a claim for reimbursement from either plan, but not both. 

(i)This act shall take effect on January 1, 2016.

SECTION 2. Section 3 of Chapter 176D, as appearing in the 2014 Official Edition, shall be amended by striking out subsection 12 in its entirety and inserting in its place the following-:

“(12) A violation of section 2B, 95, 113X, 181 to 183, inclusive, 187B to 187D, inclusive, 189, 193E, 193K or 193V of chapter 175.”

SECTION 3. Section 2 of Chapter 176G, as appearing in the 2014 Official Edition, shall be amended by inserting, after the words “seventy-five”, the following-:

“, section 1 through 193U,”