By: Harless H.B. No. 4377
A BILL TO BE ENTITLED
AN ACT
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 1451.154(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[; and
[(4) comply with the requirements of the Controlled
Substances Registration Program operated by the Department of
Public Safety].
SECTION 3. 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 4. Sections 1451.154(d) and 1451.156(d), Insurance
Code, are repealed.
SECTION 5. 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 6. This Act takes effect September 1, 2023.