HOUSE AMENDED
PRIOR PRINTER'S NOS. 237, 1596, 1761
PRINTER'S NO. 1907
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
AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF
REPRESENTATIVES, AS AMENDED, JUNE 21, 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
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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 care ." Vision services and materials for
which reimbursement is available under 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.
"Department." The Insurance Department of the Commonwealth.
"Health insurance policy." An individual or group health
insurance policy, subscriber contract , certificate or plan
issued by or through an insurer that provides covered vision
care. 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.
"Health insurer." An entity licensed by the department with
accident and health authority to issue a policy, subscriber
contract, certificate or plan that provides medical or health
care coverage and is offered or governed under any of the
following:
(1) 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
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corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"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, 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 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.
"Vision care." A provision of eye care services, materials
or both.
"Vision 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.
"Vision care supplier." A person or entity that creates,
promotes, sells, provides, advertises or administers vision care
supplies , including an optical laboratory. The term includes
persons or entities affiliated with a health insurer.
Section 2703. Vision care provider and vision care supplier
selection .
A SUBJECT TO SECTION 2705 (RELATING TO CONSUMER
ACKNOWLEDGMENT), A health insurance policy shall allow an
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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
DISCLOSURE 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 SUBJECT TO SECTION 2705 (RELATING TO CONSUMER
ACKNOWLEDGMENT), A health insurance policy that has a discount
program for noncovered services shall permit an insured who
receives vision care from an in-network vision care provider to
receive a noncovered service from the in-network vision care
provider at a nondiscounted rate, provided that the vision care
provider gives to the insured, prior to receipt of the
noncovered service, written disclosure that the vision care
provider does not participate in the insured's discount program.
SECTION 2705. CONSUMER ACKNOWLEDGMENT.
THE INSURED MUST ATTEST IN WRITING TO RECEIPT OF THE VISION
CARE PROVIDER'S WRITTEN DISCLOSURE AND THAT THE INSURED MAY HAVE
DIFFERENT FINANCIAL OBLIGATIONS UNDER SECTIONS 2703 (RELATING TO
VISION CARE PROVIDER AND VISION CARE SUPPLIER SELECTION) AND
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2704 (RELATING TO DISCOUNT ACCESS), DEPENDING ON WHETHER THE
VISION CARE SUPPLIER IS IN-NETWORK OR OUT-OF-NETWORK.
Section 2705 2706 . 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
insurance policy.
(b) Insurance Commissioner power.--Upon satisfactory
evidence of a violation of this article by any insurer or other
person within the scope of the department's investigative and
enforcement authority under subsection (a), the Insurance
Commissioner may, in the Insurance Commissioner's discretion,
pursue any of the following actions:
(1) Suspend, revoke or refuse to renew the license of
the offending person.
(2) Enter a cease and desist order.
(3) Impose a civil penalty of not more than $5,000 for
each action in violation of this article.
(4) Impose a civil penalty of not more than $10,000 for
each action in willful violation of this article.
(c) Limitation.--Penalties imposed under this article shall
not exceed $500,000 in the aggregate during a calender year.
(d) Violations by optometrists and opthalmologists.--A
violation of this article by an optometrist shall constitute
unprofessional conduct under the act of June 6, 1980 (P.L.197,
No.57), known as the Optometric Practice and Licensure Act. A
violation of this article by an ophthalmologist shall constitute
unprofessional conduct under the act of December 20, 1985
(P.L.457, No.112), known as the Medical Practice Act of 1985, or
the act of October 5, 1978 (P.L.1109, No.261), known as the
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Osteopathic Medical Practice Act.
Section 2706 2707 . Regulations.
The department may promulgate regulations as may be necessary
or appropriate to implement this article.
Section 2707 2708 . Applicability.
This article shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the department, this article 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 department, this article 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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