Regular Session 2017-2018 Senate Bill 0257 P.N. 1596

PRIOR PRINTER'S NO. 237

PRINTER'S NO. 1596

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

SENATOR WHITE, BANKING AND INSURANCE, AS AMENDED, MARCH 27, 2018

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:

"Covered vision services ." Vision services AND MATERIALS for

which reimbursement is available under an insured's A HEALTH

INSURANCE 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.

"DEPARTMENT." THE INSURANCE DEPARTMENT OF THE COMMONWEALTH.

" Insurance "HEALTH INSURANCE policy." An individual or group

health insurance policy, SUBSCRIBER contract , CERTIFICATE 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. THAT PROVIDES

COVERED VISION CARE. FOR PURPOSES OF THIS ARTICLE, THE TERM

INCLUDES VISION ONLY INSURANCE COVERAGE. 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:

"HEALTH INSURER." AN ENTITY LICENSED BY THE DEPARTMENT WITH

AN ACCIDENT AND HEALTH AUTHORITY TO ISSUE A POLICY, SUBSCRIBER

CONTRACT, CERTIFICATE OR PLAN THAT PROVIDES MEDICAL OR HEALTH

CARE COVERAGE, INCLUDING VISION COVERAGE, AND IS OFFERED OR

GOVERNED UNDER ANY OF THE FOLLOWING:

(1) This act SECTION 630, ARTICLE XXIV OR OTHER

PROVISION OF 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.

"INSURED." AN INDIVIDUAL ON WHOSE BEHALF A HEALTH INSURER IS

OBLIGATED TO PAY FOR VISION CARE UNDER A HEALTH INSURANCE

POLICY.

"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. VISION CARE.

"NONCOVERED SERVICES." VISION CARE THAT IS NOT COVERED BUT

FOR WHICH A DISCOUNT MAY BE PROVIDED UNDER THE TERMS OF A HEALTH

INSURANCE POLICY.

"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.

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"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.

(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

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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.

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.

"VISION CARE SUPPLIER." A PERSON OR ENTITY, OTHER THAN A

VISION CARE PROVIDER, THAT CREATES, PROMOTES, SELLS, PROVIDES,

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ADVERTISES OR ADMINISTERS VISION CARE, INCLUDING AN OPTICAL

LABORATORY. THE TERM INCLUDES PERSONS OR ENTITIES AFFILIATED

WITH A HEALTH INSURER.

SECTION 2703. VISION CARE PROVIDER AND VISION CARE SUPPLIER.

A HEALTH INSURANCE POLICY SHALL ALLOW AN INSURED WHO RECEIVES

VISION CARE FROM AN IN-NETWORK VISION CARE PROVIDER TO SELECT AN

OUT-OF-NETWORK VISION CARE SUPPLIER FOR RELATED VISION CARE ON

THE RECOMMENDATION OR REFERRAL OF THE IN-NETWORK VISION CARE

PROVIDER, PROVIDED THAT THE IN-NETWORK VISION CARE PROVIDER

GIVES TO THE INSURED, PRIOR TO RECOMMENDING, REFERRING,

PRESCRIBING OR ORDERING ANY VISION CARE FROM THE OUT-OF-NETWORK

VISION CARE SUPPLIER, WRITTEN NOTICE THAT:

(1) THE OUT-OF-NETWORK VISION CARE SUPPLIER IS NOT AN

IN-NETWORK VISION CARE SUPPLIER.

(2) THE INSURED HAS THE OPTION OF SELECTING AN IN-

NETWORK VISION CARE SUPPLIER.

(3) THE INSURED MAY HAVE DIFFERENT FINANCIAL OBLIGATIONS

DEPENDING ON WHETHER THE VISION CARE SUPPLIER IS IN-NETWORK

OR OUT-OF-NETWORK.

SECTION 2704. DISCOUNT ACCESS.

A HEALTH INSURANCE POLICY PROVIDING DISCOUNTS FOR NONCOVERED

SERVICES PROVIDED BY A VISION CARE PROVIDER SHALL ALLOW THE

VISION CARE PROVIDER TO OPT OUT OF THE CONTRACTUAL OBLIGATION TO

PROVIDE SUCH DISCOUNTS, PROVIDED THAT THE VISION CARE PROVIDER

PROVIDES WRITTEN DISCLOSURE TO THE INSURED THAT THE VISION CARE

PROVIDER DOES NOT PARTICIPATE IN THE INSURED'S DISCOUNT PROGRAM.

SECTION 2705. ENFORCEMENT.

(A) SCOPE.--THE DEPARTMENT MAY INVESTIGATE AND ENFORCE THE

PROVISIONS OF THIS ARTICLE ONLY INSOFAR AS THE ACTIONS OR

INACTIONS BEING INVESTIGATED RELATE TO COVERAGE UNDER A HEALTH

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INSURANCE POLICY.

(B) COMMISSIONER POWER.--UPON SATISFACTORY EVIDENCE OF A

VIOLATION OF THIS ARTICLE WITHIN THE SCOPE OF THE DEPARTMENT'S

INVESTIGATIVE AND ENFORCEMENT AUTHORITY UNDER SUBSECTION (A),

THE COMMISSIONER MAY, IN THE COMMISSIONER'S DISCRETION, IMPOSE

ANY OF THE PENALTIES SPECIFIED IN SECTION 5 OF THE ACT OF JUNE

25, 1997 (P.L.295, NO.29), KNOWN AS THE PENNSYLVANIA HEALTH CARE

INSURANCE PORTABILITY ACT.

UNDER THIS SECTION ARE IN ADDITION TO ANY OTHER REMEDIES OR

PENALTIES THAT MAY BE IMPOSED UNDER ANY OTHER APPLICABLE LAW OF

THIS COMMONWEALTH, INCLUDING THE ACT OF JULY 22, 1974 (P.L.589,

NO.205), KNOWN AS THE UNFAIR INSURANCE PRACTICES ACT. A

VIOLATION OF THIS ARTICLE SHALL BE DEEMED TO BE AN UNFAIR METHOD

OF COMPETITION AND AN UNFAIR OR DECEPTIVE ACT OR PRACTICE UNDER

THE UNFAIR INSURANCE PRACTICES ACT.

(D) ADMINISTRATIVE PROCEDURE.--THE ADMINISTRATIVE PROVISIONS

OF THIS SECTION SHALL BE SUBJECT TO 2 PA.C.S. CH. 5 SUBCH. A

(RELATING TO PRACTICE AND PROCEDURE OF COMMONWEALTH AGENCIES). A

PARTY AGAINST WHOM PENALTIES ARE ASSESSED IN AN ADMINISTRATIVE

ACTION MAY APPEAL TO COMMONWEALTH COURT AS PROVIDED IN 2 PA.C.S.

CH. 7 SUBCH. A (RELATING TO JUDICIAL REVIEW OF COMMONWEALTH

AGENCY ACTION).

(E) ENFORCEMENT REMEDIES.--THE ENFORCEMENT REMEDIES IMPOSED

UNDER THIS SECTION SHALL BE IN ADDITION TO ANY OTHER REMEDIES OR

PENALTIES THAT MAY BE IMPOSED UNDER THE LAWS OF THIS

COMMONWEALTH.

SECTION 2706. REGULATIONS.

THE DEPARTMENT MAY PROMULGATE REGULATIONS AS MAY BE NECESSARY

OR APPROPRIATE TO IMPLEMENT THIS ARTICLE.

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SECTION 2707. APPLICABILITY.

THIS ACT SHALL APPLY AS FOLLOWS:

(1) FOR HEALTH INSURANCE POLICIES FOR WHICH EITHER RATES

OR FORMS ARE REQUIRED TO BE FILED WITH FEDERAL GOVERNMENT OR

THE INSURANCE DEPARTMENT, THIS ACT SHALL APPLY TO ANY POLICY

FOR WHICH A FORM OR RATE IS FIRST FILED ON OR AFTER THE

EFFECTIVE DATE OF THIS SECTION.

(2) FOR HEALTH INSURANCE POLICIES FOR WHICH NEITHER

RATES NOR FORMS ARE REQUIRED TO BE FILED WITH THE FEDERAL

GOVERNMENT OR THE INSURANCE DEPARTMENT, THIS ACT SHALL APPLY

TO ANY POLICY ISSUED OR RENEWED ON OR AFTER 180 DAYS AFTER

THE EFFECTIVE DATE OF THIS SECTION.

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

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