Senate Bill No. 76
(By Senators Minard, Caldwell, Kessler, Anderson,
Boley, Sharpe, Rowe, Ross, Bowman and Deem)
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[Introduced January 9, 2002; referred to the Committee
on Banking and Insurance.]
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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-f,
relating to creating the patients' access to eye care act;
providing definitions; limitations on coverage; requiring
certain disclosures; permitting insured persons choices of 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-f, to read as
follows:
ARTICLE 25F. PATIENTS' ACCESS TO EYE CARE ACT.
§33-25F-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.
§33-25F-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 an 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.
§33-25F-3. Limitations on conditions of coverage.
(a) Health benefits policies may not prohibit the 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 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 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 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 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 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 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.
§33-25F-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 two, shall disclose in writing to enrollees,
subscribers, providers and insureds, in clear and accurate
language, the enrollees's right of direct access to an eye care
provider of that person's choice.
§33-25F-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.