89R21809 SCF-F
By: Dean, Gerdes H.B. No. 3211
Substitute the following for H.B. No. 3211:
By: Dean C.S.H.B. No. 3211
A BILL TO BE ENTITLED
AN ACT
relating to the participation of optometrists and therapeutic
optometrists in managed care plans providing vision benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 1451.153(a) and (b), Insurance Code,
are amended to read as follows:
(a) A managed care plan may not:
(1) discriminate against a health care practitioner
because the practitioner is an optometrist or a therapeutic
optometrist;
(2) restrict or discourage a plan participant from
obtaining covered vision or medical eye care services or procedures
from a participating optometrist or therapeutic optometrist solely
because the practitioner is an optometrist or therapeutic
optometrist;
(3) exclude an optometrist or a therapeutic
optometrist as a participating practitioner in the plan because the
optometrist or therapeutic optometrist does not have medical staff
privileges at a hospital or at a particular hospital;
(4) identify a participating optometrist or
therapeutic optometrist differently from another optometrist or
therapeutic optometrist based on:
(A) a discount or incentive offered on a medical
or vision care product or service, as defined by Section 1451.155,
that is not a covered product or service, as defined by Section
1451.155, by the optometrist or therapeutic optometrist;
(B) the dollar amount, volume amount, or percent
usage amount of any product or good purchased by the optometrist or
therapeutic optometrist; or
(C) the brand, source, manufacturer, or supplier
of a medical or vision care product or service, as defined by
Section 1451.155, utilized by the optometrist or therapeutic
optometrist to practice optometry;
(5) incentivize, recommend, encourage, persuade, or
attempt to persuade an enrollee to obtain covered or uncovered
products or services:
(A) at any particular participating optometrist
or therapeutic optometrist instead of another participating
optometrist or therapeutic optometrist;
(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 or
therapeutic optometrist; 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 or therapeutic optometrist;
(6) exclude an optometrist or a therapeutic
optometrist as a participating practitioner in the plan because the
services or procedures provided by the optometrist or therapeutic
optometrist may be provided by another type of health care
practitioner; [or]
(7) as a condition for a therapeutic optometrist to be
included in one or more of the plan's medical panels, require the
therapeutic optometrist to be included in, or to accept the terms of
payment under or for, a particular vision panel in which the
therapeutic optometrist does not otherwise wish to be included; or
(8) exclude an optometrist or a therapeutic
optometrist as a participating practitioner in the plan if the
optometrist or therapeutic optometrist satisfies the plan's
credentialing requirements and agrees to the plan's contractual
terms.
(b) A managed care plan shall:
(1) include optometrists and therapeutic optometrists
as participating health care practitioners in the plan;
(2) include the name of a participating optometrist or
therapeutic optometrist in any list of participating health care
practitioners and give equal prominence to each name;
(3) provide directly to an optometrist, therapeutic
optometrist, 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 or a therapeutic optometrist
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 and that allows the optometrist or therapeutic
optometrist to submit details for both services and vision care
products to facilitate the authorization, submission, and
reimbursement of claims; [and]
(6) describe all reimbursable medical or vision care
products or services covered under the plan using the standardized
codes, names, and definitions published in the Healthcare Common
Procedure Coding System, including:
(A) Level I codes published by the American
Medical Association; and
(B) Level II codes published by the Centers for
Medicare and Medicaid Services; and
(7) allow an optometrist or a therapeutic optometrist
to receive reimbursement through an electronic funds transfer.
SECTION 2. Subchapter D, Chapter 1451, Insurance Code, is
amended by adding Section 1451.1545 to read as follows:
Sec. 1451.1545. PARTICIPATION IN VISION CARE PLAN; EFFECT
ON OTHER PLANS. (a) In this section, "vision care plan" has the
meaning assigned by Section 1451.157(a).
(b) A vision care plan issuer must include on the issuer's
Internet website a method for a licensed optometrist or therapeutic
optometrist to submit an application for inclusion as a
participating provider in the plan. The application:
(1) may only require an applicant to provide:
(A) standardized information prescribed by rules
adopted under Section 1452.052 that is applicable to an optometrist
or therapeutic optometrist; or
(B) information specified on the Council for
Affordable Quality Healthcare credentialing application; and
(2) must impose the same application requirements on
each optometrist and therapeutic optometrist.
(c) A vision care plan issuer shall:
(1) not later than the 10th business day after the date
the issuer receives an application described by Subsection (b) that
meets the plan's application requirements, electronically deliver
to the applicant a participating provider contract, including
applicable reimbursement fee schedules, provider handbooks, and
provider manuals;
(2) not later than the 30th business day after the date
the issuer receives an application described by Subsection (b),
complete the credentialing determination and:
(A) approve the application and deliver to the
applicant a contract described by Subdivision (1) for acceptance
and signature by the approved applicant; or
(B) deny the application and, not later than the
10th business day after the date of the denial, deliver to the
applicant a written explanation of the issuer's decision; and
(3) not later than the 20th business day after the date
an approved applicant accepts the contract delivered under
Subdivision (2)(A), include the credentialed and approved
applicant as a participating provider in the plan.
(d) A vision care plan issuer:
(1) may only consider information included in an
optometrist's or therapeutic optometrist's credentialing
application in making a credentialing determination; and
(2) shall impose the same credentialing requirements
on each applicant optometrist or therapeutic optometrist.
(e) A vision care plan issuer must allow an optometrist or
therapeutic optometrist to be a participating provider to the full
extent of the optometrist's or therapeutic optometrist's license on
all of the issuer's:
(1) vision care plans and other managed care plans
with vision benefits that have enrollees located in this state; and
(2) vision panels, as defined by Section 1451.154.
(f) Subsection (e) may not be construed to require a vision
plan issuer to contract with an optometrist or a therapeutic
optometrist for a particular covered product or service as defined
by Section 1451.155.
(g) A vision care plan issuer may not exclude an optometrist
or a therapeutic optometrist as a participating provider in the
plan because of:
(1) the aggregate number of optometrists or
therapeutic optometrists on a vision panel as defined by Section
1451.154, including the aggregate number of optometrists or
therapeutic optometrists on a vision panel in a geographic service
area; or
(2) the time, distance, and appointment availability
for a patient to access a participating practitioner.
SECTION 3. Section 1451.155, Insurance Code, is amended by
adding Subsection (i) to read as follows:
(i) A contract between a managed care plan and an
optometrist or therapeutic optometrist must:
(1) include a fee schedule that includes and
individually identifies each medical or vision care product or
service covered under the plan; and
(2) use the standardized codes, names, and definitions
described by Section 1451.153 to describe all reimbursable medical
or vision care products or services covered under the plan.
SECTION 4. Section 1451.157(a)(2), Insurance Code, is
amended to read as follows:
(2) "Vision care plan" means a managed care plan that:
(A) is offered in the form of a limited-scope
policy, agreement, contract, or evidence of coverage; and
(B) [that] provides coverage for eye care
expenses but does not provide comprehensive medical coverage.
SECTION 5. The changes in law made by this Act apply only to
a contract between a vision care plan issuer and an optometrist or
therapeutic optometrist entered into or renewed on or after the
effective date of this Act.
SECTION 6. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2025.