(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 care benefits" means coverage for the diagnosis, treatment and management of eye disease and injury.
(d) "Health benefit policy" means any individual or group plan, policy or contract providing medical, hospital or surgical coverage issued, delivered, issued for delivery or renewed in this state by an insurer, after the first day of January, two thousand one. It does not include credit accident and sickness, long-term care, medicare supplement, champus supplement, disability or limited benefits policies.
(e) "Insurer" means any health care corporation, health maintenance organization, accident and sickness insurer, nonprofit hospital service corporation, nonprofit medical service corporation or similar entity.
(f) "Vision care benefits" means benefits for the refraction of the eyes and other optical benefits.
(b)When any health benefits policy provides for the payment of eye care benefits or vision care benefits, such policy shall be construed to include payment to all eye care providers who provide benefits within the scope of their providers' licenses.
(c)Any limitation or condition placed upon services, diagnosis or treatment by or payment to a particular type of licensed provider shall apply equally to all licensed providers without unfair discrimination as to the usual and customary treatment procedures of an eye care provider.
(d)Any health benefits policy that includes eye care benefits, including a diabetic retinal examination, shall provide each covered person diagnosed with diabetes direct access to an eye care provider of their choice from the insurer's panel of providers independent of, and without referral from, any other provider or entity for one annual diabetic retinal examination. The eye care provider shall provide copies of the results of the examination to the covered person's primary care physician. No other services shall be provided to the covered person by the eye care provider without the prior authorization of the insurer or of its designee. This benefit shall be subject to all coinsurance, deductibles, copayments and other policy requirements. When the diabetic retinal examination reveals the beginning stages of an abnormal condition, access to future examinations shall be subject to prior authorization from a primary care physician.
(e)Any health benefits policy that includes eye care benefits or vision care benefits shall include both optometrists and ophthalmologists.
(f)This article may not be construed to require any health benefits policy to cover any specific health care service.
(g)This article may not be construed to require a health benefit plan or an insurer to include on the insurer's panel of providers all providers willing to meet the terms and conditions of participation as a plan provider.
Note: WV Code updated with legislation passed through the 2012 1st Special Session
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