Senate Bill No. 167
(By Senators Bowman, Kessler, McKenzie, Edgell, Dittmar,
Dawson, Minard and Plymale)
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[Introduced January 21, 2000; referred to the Committee
Banking and Insurance; and then to the Committee on Finance.]
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A BILL to amend chapter thirty-three of the code of West
Virginia, one thousand nine hundred thirty-one, as amended,
by adding thereto a new article, designated article
twenty-five-e, relating to creating the patient's access to
eye care act; providing definitions; limitations on
coverage; requiring certain disclosures; permitting insured
persons choices of panel eye care providers; and other
rights.
Be it enacted by the Legislature of West Virginia:
That chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article twenty-five-e,
to read as follows:
ARTICLE 25E. PATIENTS' ACCESS TO EYE CARE ACT.
§33-25E-1. Short title; legislative findings and purpose.
This article may be referred to as the "Patients' Access to
Eye Care Act."
The Legislature finds and declares the adequate delivery of
eye care services (including, but not limited to, diagnosis,
treatment and management of eye disease and injury) requires
direct access to eye care providers without prior authorization
or referral from any other provider or entity.
§33-25E-2. Definitions.
For the purposes of this article:
(a) "Covered person" means an individual enrolled in a
health benefit plan or an eligible dependent of that person.
(b) "Eye care provider" means an optometrist or
ophthalmologist licensed by the state of West Virginia.
(c) "Eye or vision care benefits" means those services and
material which are provided by a panel eye care provider who is
functioning within the scope of the provider's license as
determined by the appropriate licensing board.
(d) "Health benefit policy" means any individual or group
plan, policy or contract for health care services issued,
delivered, issued for delivery or renewed in this state by a
health care corporation, health maintenance organization,
accident and sickness insurer, fraternal benefit society,
nonprofit hospital service corporation, nonprofit medical service
corporation or similar entity, when the policy or plan covers any
eye or vision care benefits including, but not limited to,
diagnosis and treatment of eye disease or injury, as well as
ocular manifestations of other diseases or conditions.
§33-25E-3. Limitations on conditions of coverage.
(a) Health benefits policies may not prohibit the panel eye
care provider from giving covered services to the covered persons
at the highest level of licensure and competence as determined
by the provider's licensing board.
(b) Health benefits policies may not require that the panel
eye care provider hold hospital staff privileges or include any
other condition or requirement not necessary for delivery of eye
care upon the providers that would have the effect of excluding
an individual panel eye care provider or class of eye care
providers from participation in the health care plan.
(c) Health benefits policies may not discriminate against an
individual panel eye care provider or a class of eye care
providers in the amount of reimbursement, copayment or other
financial compensation for the same or essentially similar
services provided by the health benefits policy as defined by
established diagnostic and procedure codes.
(d) Health benefits policies may not promote or recommend
any class of panel eye care providers to the detriment of any
other class of providers for the same or essentially similar eye
care service.
(e) Any health benefits policy that includes eye or vision
care benefits shall guarantee that all covered persons who are
eligible for eye or vision care benefits under a health benefits
policy must have direct access to the panel eye care provider of
their choice independent of, and without referral from, any other
provider or entity.
(f) Any health benefits policy that includes eye or vision
care benefits shall include both optometrists and
ophthalmologists in a manner that does not discriminate against
any class of panel eye care provider and in a manner that ensures
plan enrollees timely access and geographic access.
(g) This article may not be construed to require any health
benefits policy to cover any specific health care service and no
condition or measure may have the effect of excluding any type of
class of provider licensed to provide that service.
(h) This article may not be construed to require a health
benefit plan to include on the provider panel all providers
willing to meet the terms and conditions of participation as a
plan provider.
§33-25E-4. Required disclosure.
Every health benefits policy that is issued, delivered,
issued for redelivery or renewed in this state on or after the
first day of July, two thousand, shall disclose in writing to
enrollees, subscribers, providers and insureds, in clear and
accurate language, the enrollees's right of direct access to a
panel eye care provider of that person's choice.
§33-25E-5. Primary care provider.
This article does not prevent a covered person from having
direct access to that person's primary care provider for the
treatment of eye disease or injury and being reimbursed in
accordance with the terms and fee schedule of the health benefits
plan.
NOTE: This bill creates the Patient's Access To Eye Care Act
and sets out coverage extended to persons insured for eye care.
This article is new; therefore, strike-throughs and
underscoring have been omitted.