Regular Session 2015-2016 Senate Bill 0978 P.N. 2176

PRIOR PRINTER'S NO. 1206

PRINTER'S NO. 2176

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

No.

978

Session of

2015

INTRODUCED BY WARD, SCARNATI, FOLMER, RAFFERTY, GORDNER, VOGEL,

BOSCOLA, McGARRIGLE, TEPLITZ, YUDICHAK, BROOKS, HUTCHINSON,

SABATINA, WOZNIAK, STEFANO, WHITE, SCHWANK, LEACH, McILHINNEY

AND CORMAN, AUGUST 14, 2015

SENATOR WHITE, BANKING AND INSURANCE, AS AMENDED,

OCTOBER 19, 2016

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," providing for quality eye care for

insured Pennsylvanians.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. The act of May 17, 1921 (P.L.682, No.284), known

as The Insurance Company Law of 1921, is amended by adding an

article to read:

ARTICLE XXVII

QUALITY EYE CARE FOR INSURED PENNSYLVANIANS

Section 2701. Short title of article.

This article shall be known and may be cited as the Quality

Eye Care for Insured Pennsylvanians Act.

Section 2702. Definitions.

The following words and phrases when used in this article

shall have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Coverage." Inclusion in an insurance policy, a vision care

plan or a government program of services, materials or both

where reimbursement from the insurer, vision care plan or

government program is provided to an eye care provider under an

enrollee's contractual plan or where reimbursement would be

available for the application of the enrollee's contractual plan

limitations on deductibles, copayments or coinsurance.

"COVERED VISION SERVICES." VISION SERVICES FOR WHICH

REIMBURSEMENT IS AVAILABLE UNDER AN INSURED'S POLICY, REGARDLESS

OF WHETHER THE REIMBURSEMENT IS CONTRACTUALLY LIMITED BY A

DEDUCTIBLE, COPAYMENT, COINSURANCE, WAITING PERIOD, ANNUAL OR

LIFETIME MAXIMUM, FREQUENCY LIMITATION OR ALTERNATIVE BENEFIT

PAYMENT.

"Enrollee." A subscriber afforded coverage for services,

materials or both under an insurance policy, a vision care plan

or a government program.

"Eye care provider." A licensed doctor of optometry

practicing under the authority of the act of June 6, 1980

(P.L.197, No.57), known as the Optometric Practice and Licensure

Act, or a licensed physician who has also completed a residency

in ophthalmology.

"Government program." A program that issues coverage for

materials or services pursuant to this act and is governed by or

subject to any of the following:

(1) The medical assistance program established under the

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act of June 13, 1967 (P.L.31, No.21), known as the Public

Welfare Code.

(2) The Children's Health Care Program established under

Article XXIII.

(3) A program administered by a Medicaid managed care

organization as defined in section 1903(m)(1)(A) of the

Social Security Act (49 Stat. 620, 42 U.S.C. § 1396b(m)(1)

(A)) that is a party to a Medicaid managed care contract with

the Department of Human Services.

(4) The Medicare program established under the Social

Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.).

(5) The Medicare Advantage program established under the

Social Security Act.

"Insurance policy." An individual or group health insurance

policy, contract or plan issued by or through an insurer, a

vision care plan or a government program that provides coverage

for materials, services or both provided by an eye care

provider. The term does not include accident only, fixed

indemnity, limited benefit, credit, dental, specified disease,

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS) supplement, long-term care or disability income,

workers' compensation or automobile medical payment insurance.

"Insurer." An entity or affiliate entity that issues an

insurance policy pursuant to this act and is subject to any one

of the following:

(1) This act.

(2) The act of December 29, 1972 (P.L.1701, No.364),

known as the Health Maintenance Organization Act.

(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan

corporations).

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(4) 40 Pa.C.S. Ch. 63 (relating to professional health

services plan corporations).

(5) A preferred provider organization.

"Licensure board." Any or all of the following, depending on

the licensure of the affected individual:

(1) The State Board of Medicine.

(2) The State Board of Osteopathic Medicine.

(3) The State Board of Optometry.

"Materials." Ophthalmic devices, including, but not limited

to, lenses, devices containing lenses, artificial intraocular

lenses, ophthalmic frames and other lens mounting apparatus,

prisms, lens treatments and coating, contact lenses and

prosthetic devices to correct, relieve or treat defects or

abnormal conditions of the human eye or its adnexa associated

with the delivery of services, materials or both by an eye care

provider.

"Physician." An individual licensed under the laws of this

Commonwealth to engage in the practice of:

(1) Medicine and surgery in all its branches within the

scope of the act of December 20, 1985 (P.L.457, No.112),

known as the Medical Practice Act of 1985.

(2) Osteopathic medicine and surgery within the scope of

the act of October 5, 1978 (P.L.1109, No.261), known as the

Osteopathic Medical Practice Act.

"Services." The delivery of any eye care services, materials

or both by an eye care provider.

"Vision care plan." An entity that creates, promotes, sells,

provides, advertises or administers an integrated or stand-alone

vision benefit plan, or a vision care insurance policy or

contract that provides coverage for materials, services or both

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to an enrollee pursuant to an insurance policy, vision care plan

or government program.

Section 2703. Restrictions on participating provider

agreements.

A participating provider agreement between an eye care

provider and an insurer, vision care plan or government program

shall comply with all of the following:

(1) The participating provider agreement may not require

that an eye care provider provide services, materials or both

at a fee limited or set by the insurer, vision care plan or

government program unless those services, materials or both

are subject to coverage and are reimbursed as covered

services or covered materials under the participating

provider agreement. THE EYE CARE PROVIDER MAY NOT BE REQUIRED

TO PROVIDE SERVICES TO THE INSURER'S INSUREDS AT A FEE SET BY

THE INSURER UNLESS THOSE SERVICES ARE COVERED VISION

SERVICES.

(2) Reimbursements paid by an insurer, vision care plan

or government program for covered services and covered

materials under the participating provider agreement shall be

reasonable and shall not provide nominal reimbursement in

order to claim that services and materials are included in

coverage COVERED VISION SERVICES under the insurance policy,

vision care plan or government program.

(3) An eye care provider may not charge more for

services and materials that are noncovered services or

noncovered materials to an enrollee of an insurer, vision

care plan or government program than the usual and customary

rate for those services and materials.

(4) The participating provider agreement may not

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restrict or limit, either directly or indirectly, the eye

care provider's choice of sources and suppliers of services

or materials or the use of optical laboratories provided by

the eye care provider to an enrollee.

(5) The terms or reimbursement rates contained in the

participating provider agreement may not be changed without a

signed acknowledgment of written consent and agreement from

the eye care provider.

Section 2704. Prohibition on contracting.

No insurance policy, vision care plan or government program

may impose a condition or restriction on an eye care provider

that is not necessary for the delivery of services or materials

or that has the effect of excluding the eye care provider from

participation in the insurance policy, vision care plan,

government program or any of the participating provider panels

for those entities.

Section 2705. Interference with other contractual

relationships.

No insurer, vision care plan or government program offering

group or individual coverage may interfere with any existing

contractual relationship, Federal or State requirement or the

doctor-patient relationship by directly communicating with an

enrollee in a manner that interferes with or contravenes those

relationships and requirements.

Section 2706. Private right of action for eye care providers.

A person adversely affected by a violation of this article

may bring an action in a court of competent jurisdiction for

injunctive relief and monetary damages and if successful in an

action, shall be entitled to recover against the opposing party

actual damages, a penalty of up to $1,000 for each day of

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violation and reasonable attorney fees and costs.

Section 2707 2705 . Penalties.

A violation of the provisions of this article by an insurer

or a vision care plan with frequency sufficient to constitute a

general business practice shall be considered a violation of the

act of July 22, 1974 (P.L.589, No.205), known as the Unfair

Insurance Practices Act, and is deemed an unfair method of

competition and an unfair deceptive act or practice pursuant to

that act.

Section 2708 2706 . Applicability.

The requirements of this article shall apply to an insurer,

insurance policy, a vision care plan or a government program and

any contracts, addendums and certificates executed, delivered,

issued for delivery, continued or renewed in this Commonwealth.

No insurance policy, vision care plan or government program

contract may be in effect longer than two years from the date of

initial signature or last renewal.

Section 2. This act shall take effect in 60 days.

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