Texas 2023 - 88th Regular

Texas House Bill HB1696 Compare Versions

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1	1	H.B. No. 1696
2	2
3	3
4	4	AN ACT
5	5	relating to the relationship between managed care plans and
6	6	optometrists and therapeutic optometrists.
7	7	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	8	SECTION 1. The heading to Subchapter D, Chapter 1451,
9	9	Insurance Code, is amended to read as follows:
10	10	SUBCHAPTER D. ACCESS TO OPTOMETRISTS [AND OPHTHALMOLOGISTS] USED
11	11	UNDER MANAGED CARE PLAN
12	12	SECTION 2. Section 1451.151, Insurance Code, is amended to
13	13	read as follows:
14	14	Sec. 1451.151. DEFINITION [DEFINITIONS]. In this
15	15	subchapter,[:
16	16	[(1)] "managed [Managed] care plan" means a plan under
17	17	which a health maintenance organization, preferred provider
18	18	benefit plan issuer, vision benefit plan issuer, vision benefit
19	19	plan administrator, or other organization provides or arranges for
20	20	health care benefits or vision benefits to plan participants and
21	21	requires or encourages plan participants to use health care
22	22	practitioners the plan designates.
23	23	[(2) "Ophthalmologist" means a physician who
24	24	specializes in ophthalmology.]
25	25	SECTION 3. Section 1451.153, Insurance Code, is amended to
26	26	read as follows:
27	27	Sec. 1451.153. USE OF OPTOMETRIST OR[,] THERAPEUTIC
28	28	OPTOMETRIST[, OR OPHTHALMOLOGIST]. (a) A managed care plan may
29	29	not:
30	30	(1) discriminate against a health care practitioner
31	31	because the practitioner is an optometrist or a[,] therapeutic
32	32	optometrist[, or ophthalmologist];
33	33	(2) restrict or discourage a plan participant from
34	34	obtaining covered vision or medical eye care services or procedures
35	35	from a participating optometrist or[,] therapeutic optometrist[,
36	36	or ophthalmologist] solely because the practitioner is an
37	37	optometrist or[,] therapeutic optometrist[, or ophthalmologist];
38	38	(3) exclude an optometrist or a[,] therapeutic
39	39	optometrist[, or ophthalmologist] as a participating practitioner
40	40	in the plan because the optometrist or[,] therapeutic optometrist[,
41	41	or ophthalmologist] does not have medical staff privileges at a
42	42	hospital or at a particular hospital;
43	43	(4) identify a participating optometrist or
44	44	therapeutic optometrist differently from another optometrist or
45	45	therapeutic optometrist based on:
46	46	(A) a discount or incentive offered on a medical
47	47	or vision care product or service, as defined by Section 1451.155,
48	48	that is not a covered product or service, as defined by Section
49	49	1451.155, by the optometrist or therapeutic optometrist;
50	50	(B) the dollar amount, volume amount, or percent
51	51	usage amount of any product or good purchased by the optometrist or
52	52	therapeutic optometrist; or
53	53	(C) the brand, source, manufacturer, or supplier
54	54	of a medical or vision care product or service, as defined by
55	55	Section 1451.155, utilized by the optometrist or therapeutic
56	56	optometrist to practice optometry;
57	57	(5) incentivize, recommend, encourage, persuade, or
58	58	attempt to persuade an enrollee to obtain covered or uncovered
59	59	products or services:
60	60	(A) at any particular participating optometrist
61	61	or therapeutic optometrist instead of another participating
62	62	optometrist or therapeutic optometrist;
63	63	(B) at a retail establishment owned by, partially
64	64	owned by, contracted with, or otherwise affiliated with the managed
65	65	care plan instead of a different participating optometrist or
66	66	therapeutic optometrist; or
67	67	(C) at any Internet or virtual provider or
68	68	retailer owned by, partially owned by, contracted with, or
69	69	otherwise affiliated with the managed care plan instead of a
70	70	different participating optometrist or therapeutic optometrist;
71	71	(6) exclude an optometrist or a[,] therapeutic
72	72	optometrist[, or ophthalmologist] as a participating practitioner
73	73	in the plan because the services or procedures provided by the
74	74	optometrist or[,] therapeutic optometrist[, or ophthalmologist]
75	75	may be provided by another type of health care practitioner; or
76	76	(7) [(5)] as a condition for a therapeutic optometrist
77	77	[or ophthalmologist] to be included in one or more of the plan's
78	78	medical panels, require the therapeutic optometrist [or
79	79	ophthalmologist] to be included in, or to accept the terms of
80	80	payment under or for, a particular vision panel in which the
81	81	therapeutic optometrist [or ophthalmologist] does not otherwise
82	82	wish to be included.
83	83	(b) A managed care plan shall:
84	84	(1) include optometrists and[,] therapeutic
85	85	optometrists[, and ophthalmologists] as participating health care
86	86	practitioners in the plan; [and]
87	87	(2) include the name of a participating optometrist
88	88	or[,] therapeutic optometrist[, or ophthalmologist] in any list of
89	89	participating health care practitioners and give equal prominence
90	90	to each name;
91	91	(3) provide directly to an optometrist, therapeutic
92	92	optometrist, or plan enrollee immediate access by electronic means
93	93	to an enrollee's complete plan coverage information, including
94	94	in-network and out-of-network coverage details;
95	95	(4) publish complete plan information, including
96	96	in-network and out-of-network coverage details, with any marketing
97	97	materials that describe the plan benefits, including any summary
98	98	plan description;
99	99	(5) allow an optometrist or a therapeutic optometrist
100	100	to utilize any third-party claim-filing service, billing service,
101	101	or electronic data interchange clearinghouse company that uses the
102	102	standardized claim submission protocol of the National Uniform
103	103	Claim Committee and that allows the optometrist or therapeutic
104	104	optometrist to submit details for both services and vision care
105	105	products to facilitate the authorization, submission, and
106	106	reimbursement of claims; and
107	107	(6) allow an optometrist or a therapeutic optometrist
108	108	to receive reimbursement through an electronic funds transfer.
109	109	(c) For the purposes of Subsection (a)(7) [(a)(5)],
110	110	"medical panel" and "vision panel" have the meanings assigned by
111	111	Section 1451.154(a).
112	112	SECTION 4. Section 1451.154(a)(2), Insurance Code, is
113	113	amended to read as follows:
114	114	(2) "Vision panel" means the optometrists and[,]
115	115	therapeutic optometrists[, and ophthalmologists] who are listed as
116	116	participating providers for routine eye examinations under a
117	117	managed care plan or who a patient seeking a routine eye examination
118	118	is encouraged or required to use under a managed care plan.
119	119	SECTION 5. Section 1451.154(c), Insurance Code, is amended
120	120	to read as follows:
121	121	(c) A therapeutic optometrist who is included in a managed
122	122	care plan's medical panels under Subsection (b) must:
123	123	(1) abide by the terms and conditions of the managed
124	124	care plan;
125	125	(2) satisfy the managed care plan's credentialing
126	126	standards for therapeutic optometrists; and
127	127	(3) provide proof that the Texas Optometry Board
128	128	considers the therapeutic optometrist's license to practice
129	129	therapeutic optometry to be in good standing[; and
130	130	[(4) comply with the requirements of the Controlled
131	131	Substances Registration Program operated by the Department of
132	132	Public Safety].
133	133	SECTION 6. Section 1451.155, Insurance Code, is amended to
134	134	read as follows:
135	135	Sec. 1451.155. CONTRACTS WITH OPTOMETRISTS OR THERAPEUTIC
136	136	OPTOMETRISTS. (a) In this section:
137	137	(1) "Chargeback" means a dollar amount, fee,
138	138	surcharge, or item of value that reduces, modifies, or offsets all
139	139	or part of the patient responsibility, provider reimbursement, or
140	140	fee schedule for a covered product or service.
141	141	(2) "Covered product or service" means a medical or
142	142	vision care product or service for which reimbursement is available
143	143	under an enrollee's managed care plan contract or for which
144	144	reimbursement is available subject to a contractual limitation,
145	145	including:
146	146	(A) a deductible;
147	147	(B) a copayment;
148	148	(C) coinsurance;
149	149	(D) a waiting period;
150	150	(E) an annual or lifetime maximum limit;
151	151	(F) a frequency limitation; or
152	152	(G) an alternative benefit payment.
153	153	(3) [(2)] "Medical or vision [Vision] care product or
154	154	service" means a product or service provided within the scope of the
155	155	practice of optometry or therapeutic optometry under Chapter 351,
156	156	Occupations Code.
157	157	(a-1) For the purposes of this section, a product or service
158	158	reimbursed to an optometrist or therapeutic optometrist at a
159	159	nominal or de minimis rate is not a covered product or service.
160	160	(a-2) For the purposes of this section, a product or service
161	161	reimbursed to an optometrist or therapeutic optometrist solely by
162	162	the enrollee is not a covered product or service.
163	163	(b) A contract between a managed care plan [an insurer] and
164	164	an optometrist or therapeutic optometrist may not limit the fee the
165	165	optometrist or therapeutic optometrist may charge for a product or
166	166	service that is not a covered product or service.
167	167	(c) A contract between a managed care plan [an insurer] and
168	168	an optometrist or therapeutic optometrist may not require a
169	169	discount on a product or service that is not a covered product or
170	170	service.
171	171	(d) A contract between a managed care plan and an
172	172	optometrist or therapeutic optometrist may not contain a provision
173	173	authorizing a chargeback to the patient, optometrist, or
174	174	therapeutic optometrist if the chargeback is for a covered product
175	175	or service that the managed care plan does not incur the cost to
176	176	produce, deliver, or provide to the patient, optometrist, or
177	177	therapeutic optometrist.
178	178	(e) A contract between a managed care plan and an
179	179	optometrist or therapeutic optometrist may not contain a provision
180	180	authorizing a reimbursement fee schedule for a covered product or
181	181	service that is different from the fee schedule applicable to
182	182	another optometrist or therapeutic optometrist because of the
183	183	optometrist's or therapeutic optometrist's choice of:
184	184	(1) optical laboratory;
185	185	(2) source or supplier of:
186	186	(A) contact lenses;
187	187	(B) ophthalmic lenses;
188	188	(C) ophthalmic glasses frames; or
189	189	(D) covered or uncovered products or services;
190	190	(3) equipment used for patient care;
191	191	(4) retail optical affiliation;
192	192	(5) vision support organization;
193	193	(6) group purchasing organization;
194	194	(7) doctor alliance;
195	195	(8) professional trade association membership;
196	196	(9) affiliation with an arrangement defined as a
197	197	franchise by 16 C.F.R. Part 436;
198	198	(10) electronic health record software, electronic
199	199	medical record software, or practice management software; or
200	200	(11) third-party claim-filing service, billing
201	201	service, or electronic data interchange clearinghouse company.
202	202	(f) A managed care plan may not change a contract between a
203	203	managed care plan and an optometrist or therapeutic optometrist,
204	204	including terms, reimbursements, or fee schedules, unless the
205	205	managed care plan provides written notice of the change to the
206	206	optometrist or therapeutic optometrist at least 90 days before the
207	207	date the proposed change takes effect.
208	208	(g) A contract between a managed care plan and an
209	209	optometrist or therapeutic optometrist may not contain a provision
210	210	requiring the optometrist or therapeutic optometrist to provide a
211	211	covered product at a loss.
212	212	(h) A contract between a managed care plan and an
213	213	optometrist or therapeutic optometrist may not contain a provision
214	214	requiring the optometrist or therapeutic optometrist to accept a
215	215	reimbursement payment in the form of a virtual credit card or any
216	216	other payment method where a processing fee, administrative fee,
217	217	percentage amount, or dollar amount is assessed to receive the
218	218	reimbursement payment, except in the case of a nominal fee assessed
219	219	by the optometrist's or therapeutic optometrist's bank to receive
220	220	an electronic funds transfer.
221	221	SECTION 7. The heading to Section 1451.156, Insurance Code,
222	222	is amended to read as follows:
223	223	Sec. 1451.156. CERTAIN CONDUCT PROHIBITED [CONDUCT].
224	224	SECTION 8. Section 1451.156(a), Insurance Code, is amended
225	225	to read as follows:
226	226	(a) A managed care plan, as described by Section
227	227	1451.152(a), may not directly or indirectly:
228	228	(1) control or attempt to control the professional
229	229	judgment, manner of practice, or practice of an optometrist or
230	230	therapeutic optometrist;
231	231	(2) employ an optometrist or therapeutic optometrist
232	232	to provide a vision care product or service as defined by Section
233	233	1451.155;
234	234	(3) pay an optometrist or therapeutic optometrist for
235	235	a service not provided;
236	236	(4) reimburse an optometrist or therapeutic
237	237	optometrist a different amount for a covered product or service as
238	238	defined by Section 1451.155 because of the optometrist's or
239	239	therapeutic optometrist's choice of:
240	240	(A) optical laboratory;
241	241	(B) source or supplier of:
242	242	(i) contact lenses;
243	243	(ii) ophthalmic lenses;
244	244	(iii) ophthalmic glasses frames; or
245	245	(iv) covered or uncovered products or
246	246	services;
247	247	(C) equipment used for patient care;
248	248	(D) retail optical affiliation;
249	249	(E) vision support organization;
250	250	(F) group purchasing organization;
251	251	(G) doctor alliance;
252	252	(H) professional trade association membership;
253	253	(I) affiliation with an arrangement defined as a
254	254	franchise by 16 C.F.R. Part 436;
255	255	(J) electronic health record software,
256	256	electronic medical record software, or practice management
257	257	software; or
258	258	(K) third-party claim-filing service, billing
259	259	service, or electronic data interchange clearinghouse company;
260	260	(5) restrict, [or] limit, or influence an
261	261	optometrist's or therapeutic optometrist's choice of sources or
262	262	suppliers of services or materials, including optical laboratories
263	263	used by the optometrist or therapeutic optometrist to provide
264	264	services or materials to a patient;
265	265	(6) restrict, limit, or influence an optometrist's or
266	266	therapeutic optometrist's choice of electronic health record
267	267	software, electronic medical record software, or practice
268	268	management software;
269	269	(7) restrict, limit, or influence an optometrist's or
270	270	therapeutic optometrist's choice of third-party claim-filing
271	271	service, billing service, or electronic data interchange
272	272	clearinghouse company;
273	273	(8) restrict or limit an optometrist's or therapeutic
274	274	optometrist's access to a patient's complete plan coverage
275	275	information, including in-network and out-of-network coverage
276	276	details;
277	277	(9) apply a chargeback, as defined by Section
278	278	1451.155, to a patient, optometrist, or therapeutic optometrist if
279	279	the chargeback is for a covered product or service that the managed
280	280	care plan does not incur the cost to produce, deliver, or provide to
281	281	the patient, optometrist, or therapeutic optometrist;
282	282	(10) require an optometrist or therapeutic
283	283	optometrist to provide a covered product at a loss; [or]
284	284	(11) [(5)] require an optometrist or therapeutic
285	285	optometrist to disclose a patient's confidential or protected
286	286	health information unless the disclosure is authorized by the
287	287	patient or permitted without authorization under the Health
288	288	Insurance Portability and Accountability Act of 1996 (42 U.S.C.
289	289	Section 1320d et seq.) or under Section 602.053;
290	290	(12) require an optometrist or therapeutic
291	291	optometrist to disclose or report a medical history or diagnosis as
292	292	a condition to file a claim, adjudicate a claim, or receive
293	293	reimbursement for a routine or wellness vision eye exam;
294	294	(13) require an optometrist or therapeutic
295	295	optometrist to disclose or report a patient's glasses prescription,
296	296	contact lens prescription, ophthalmic device measurements, facial
297	297	photograph, or unique anatomical measurements as a condition to
298	298	file a claim, adjudicate a claim, or receive reimbursement for a
299	299	claim unless the information is needed for the managed care plan to
300	300	manufacture or cause to be manufactured a covered product that is
301	301	submitted on the claim;
302	302	(14) require an optometrist or therapeutic
303	303	optometrist to disclose any patient information, other than
304	304	information identified on the version of the Health Insurance Claim
305	305	Form approved by the National Uniform Claim Committee as of March 1,
306	306	2023, as a condition to file a claim, adjudicate a claim, or receive
307	307	reimbursement for a claim unless the information is needed for the
308	308	managed care plan to manufacture or cause to be manufactured a
309	309	covered product that is submitted on the claim; or
310	310	(15) require an optometrist or therapeutic
311	311	optometrist to accept a reimbursement payment in the form of a
312	312	virtual credit card or any other payment method where a processing
313	313	fee, administrative fee, percentage amount, or dollar amount is
314	314	assessed to receive the reimbursement payment, except in the case
315	315	of a nominal fee assessed by the optometrist's or therapeutic
316	316	optometrist's bank to receive an electronic funds transfer.
317	317	SECTION 9. Subchapter D, Chapter 1451, Insurance Code, is
318	318	amended by adding Sections 1451.157 and 1451.158 to read as
319	319	follows:
320	320	Sec. 1451.157. EXTRAPOLATION PROHIBITED. (a) In this
321	321	section:
322	322	(1) "Extrapolation" means a mathematical process or
323	323	technique used by a vision care plan in the audit of an optometrist
324	324	or therapeutic optometrist to estimate audit results or findings
325	325	for a larger batch or group of claims not reviewed by the plan.
326	326	(2) "Vision care plan" means a limited-scope policy,
327	327	agreement, contract, or evidence of coverage that provides coverage
328	328	for eye care expenses but does not provide comprehensive medical
329	329	coverage.
330	330	(b) A vision care plan may not use extrapolation to complete
331	331	an audit of a participating optometrist or therapeutic optometrist.
332	332	Any additional payment due to a participating optometrist or
333	333	therapeutic optometrist or any refund due to the vision care plan
334	334	must be based on the actual overpayment or underpayment and may not
335	335	be based on an extrapolation.
336	336	Sec. 1451.158. ENFORCEMENT OF SUBCHAPTER. (a) A violation
337	337	of this subchapter by a managed care plan is subject to an
338	338	administrative penalty under Chapter 84.
339	339	(b) The commissioner shall take all reasonable actions to
340	340	ensure compliance with this subchapter, including issuing orders to
341	341	enforce this subchapter.
342	342	SECTION 10. Sections 1451.154(d) and 1451.156(d),
343	343	Insurance Code, are repealed.
344	344	SECTION 11. The changes in law made by this Act apply only
345	345	to a contract between a managed care plan or vision care plan and an
346	346	optometrist or a therapeutic optometrist entered into or renewed,
347	347	or a managed care plan or vision care plan delivered, issued for
348	348	delivery, or renewed, on or after January 1, 2024. A contract
349	349	entered into or renewed, or a managed care plan or vision care plan
350	350	delivered, issued for delivery, or renewed, before January 1, 2024,
351	351	is governed by the law as it existed immediately before the
352	352	effective date of this Act, and that law is continued in effect for
353	353	that purpose.
354	354	SECTION 12. This Act takes effect September 1, 2023.
355	355	______________________________ ______________________________
356	356	President of the Senate Speaker of the House
357	357	I certify that H.B. No. 1696 was passed by the House on May 8,
358	358	2023, by the following vote: Yeas 143, Nays 0, 1 present, not
359	359	voting.
360	360	______________________________
361	361	Chief Clerk of the House
362	362	I certify that H.B. No. 1696 was passed by the Senate on May
363	363	23, 2023, by the following vote: Yeas 31, Nays 0.
364	364	______________________________
365	365	Secretary of the Senate
366	366	APPROVED: _____________________
367	367	Date
368	368	_____________________
369	369	Governor