PRINTER'S NO. 237
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
257
Session of
2017
INTRODUCED BY WARD, WHITE, SCARNATI, GORDNER, SCHWANK, BROOKS,
FOLMER, YUDICHAK, HUTCHINSON, COSTA, STEFANO, AUMENT, BOSCOLA
AND RAFFERTY, JANUARY 27, 2017
REFERRED TO BANKING AND INSURANCE, JANUARY 27, 2017
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.
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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:
"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
act of June 13, 1967 (P.L.31, No.21), known as the Human
Services Code.
(2) 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.
(3) The Medicare program established under the Social
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Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.).
(4) 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).
(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
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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 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
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 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.
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(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
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
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 . Penalties.
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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 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.
Section 2. This act shall take effect in 60 days.
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