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House
File
2249
-
Introduced
HOUSE
FILE
2249
BY
BOSSMAN
A
BILL
FOR
An
Act
relating
to
vision
benefit
plans,
vision
benefit
1
managers,
vision
care
providers,
and
vision
care
provider
2
contracts
and
including
civil
penalties
and
effective
date
3
and
applicability
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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Section
1.
NEW
SECTION
.
514M.1
Definitions.
1
As
used
in
this
chapter,
unless
the
context
otherwise
2
requires:
3
1.
“Chargeback”
means
a
dollar
amount,
fee,
surcharge,
4
rebate,
or
item
of
value
that
reduces,
modifies,
or
offsets
5
all
or
part
of
the
covered
person’s
responsibility,
provider
6
reimbursement,
allowed
amount,
or
fee
schedule
for
a
covered
7
service
or
covered
material.
8
2.
“Cost
sharing”
means
any
coverage
limit,
copayment,
9
coinsurance,
deductible,
or
other
out-of-pocket
expense
10
requirement.
11
3.
“Covered
material”
means
a
material
for
which
12
reimbursement
from
a
vision
benefit
manager
or
subcontractor
13
is
provided
to
a
vision
care
provider
by
a
covered
person’s
14
plan
contract,
or
for
which
a
reimbursement
would
be
available
15
but
for
the
application
of
the
covered
person’s
cost
sharing,
16
regardless
of
how
the
materials
are
listed
or
described
in
a
17
covered
person’s
benefit
plan’s
definition
of
benefits.
18
4.
“Covered
person”
means
a
policyholder,
subscriber,
19
enrollee,
or
other
individual
participating
in
a
health
benefit
20
plan,
vision
benefit
plan,
or
vision
benefit
discount
plan
21
that
provides
for
third-party
payment
or
prepayment
of
covered
22
services
or
covered
materials.
23
5.
“Covered
service”
means
a
service
performed
by
a
24
vision
care
provider
for
which
reimbursement
from
a
vision
25
benefit
manager
or
subcontractor
is
provided
to
a
vision
care
26
provider
by
a
covered
person’s
plan
contract,
or
for
which
a
27
reimbursement
would
be
available
but
for
the
application
of
the
28
covered
person’s
cost
sharing,
regardless
of
how
the
services
29
are
listed
or
described
in
a
covered
person’s
benefit
plan’s
30
definition
of
benefits.
31
6.
“Health
benefit
plan”
means
a
policy,
contract,
32
certificate,
or
agreement
offered
or
issued
by
a
third-party
33
administrator
or
a
subcontractor
to
provide,
deliver,
arrange
34
for,
pay
for,
or
reimburse
any
of
the
costs
of
health
care
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services.
1
7.
“Material”
means
ophthalmic
devices
including
but
not
2
limited
to
lenses,
devices
containing
lenses,
artificial
3
intraocular
lenses,
ophthalmic
frames
and
other
lens
mounting
4
apparatus,
prisms,
lens
treatments
and
coatings,
contact
5
lenses,
low-vision
devices,
vision
therapy
devices,
and
6
prosthetic
devices
to
correct,
relieve,
or
treat
defects
or
7
abnormal
conditions
of
the
human
eye
or
its
adnexa,
or
any
8
material
allowed
to
be
utilized
by
the
Iowa
board
of
optometry.
9
8.
“Participating
vision
care
provider”
means
a
vision
care
10
provider
that
has
entered
into
a
contractual
agreement
or
11
other
business
relationship
with
a
vision
benefit
manager
or
12
subcontractor
to
provide
covered
services
or
covered
materials.
13
9.
“Subcontractor”
means
a
person,
including
but
not
14
limited
to
the
person’s
agents,
servants,
brokers,
wholesalers,
15
distributors,
partially
or
wholly
owned
subsidiaries,
and
16
controlled
organizations,
that
is
contracted
by
the
vision
17
benefit
manager
to
supply
services
or
materials
to
another
18
vision
benefit
manager,
vision
care
provider,
or
covered
person
19
to
execute
or
fulfill
the
health
benefit
plan,
vision
benefit
20
plan,
or
vision
benefit
discount
plan
of
a
vision
benefit
21
manager.
22
10.
“Third-party
administrator”
means
a
person
that
23
provides
services
including
but
not
limited
to
administrative,
24
operational,
regulatory,
human
resource,
compliance,
and
claim
25
adjudication
services
for
a
vision
benefit
manager,
individual,
26
company,
organization,
group,
or
other
entity
under
a
contract
27
or
agreement.
28
11.
“Vision
benefit
discount
plan”
means
a
policy,
contract,
29
or
plan
offered
by
a
vision
benefit
manager
to
a
covered
person
30
that
exclusively
provides
for
a
discount
for
vision
care
31
services
or
materials.
32
12.
“Vision
benefit
manager”
means
a
person,
including
but
33
not
limited
to
a
third-party
administrator
or
a
subcontractor,
34
that
creates,
promotes,
sells,
provides,
advertises,
or
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administers
an
integrated
or
stand-alone
vision
benefit
plan,
1
vision
benefit
discount
plan,
or
other
insurance
policy
or
2
contract
which
provides
vision
benefits
or
discounts
pertaining
3
to
the
provision
of
covered
services
or
covered
materials
to
4
a
covered
person.
5
13.
“Vision
benefit
plan”
means
a
policy,
contract,
or
6
plan
offered
or
issued
by
a
vision
benefit
manager
to
provide,
7
deliver,
arrange
for,
pay
for,
or
reimburse
any
of
the
costs
of
8
health
care
services
and
vision
care
materials
and
services.
9
14.
“Vision
care
provider”
means
an
optometrist
licensed
10
under
chapter
154,
or
a
person
engaged
in
the
practice
of
11
medicine
and
surgery
or
osteopathic
medicine
and
surgery
12
licensed
under
chapter
148.
13
Sec.
2.
NEW
SECTION
.
514M.2
Standards
of
conduct
——
vision
14
benefit
managers.
15
1.
A
reimbursement
paid
by
a
vision
benefit
manager
for
16
a
covered
service
or
covered
material
must
meet
all
of
the
17
following
requirements:
18
a.
Be
clearly
and
individually
listed
on
a
reimbursement
19
schedule
made
available
to
the
vision
care
provider.
20
b.
Use
the
Medicare
health
care
procedure
coding
system
and
21
current
procedural
terminology
codes.
22
c.
Not
be
less
than
the
calendar
year
Medicare
physician
fee
23
schedule
for
a
covered
service
or
covered
material
in
effect
at
24
the
time
of
either
of
the
following:
25
(1)
On
the
date
that
a
contract
is
offered
to
the
vision
26
care
provider
by
a
vision
benefit
manager.
27
(2)
Within
five
business
days
from
the
date
a
participating
28
vision
care
provider
requests
to
execute
a
contract
with
the
29
vision
benefit
manager.
30
2.
Reimbursement
rate
fee
schedules
for
vision
care
31
providers
shall
be
increased
annually
to
adjust
for
inflation
32
and,
to
the
extent
data
is
available,
the
rate
of
inflation
for
33
office
practice
expenses
for
the
relevant
vision
care
provider
34
category.
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3.
The
period
of
time
prescribed
by
a
contract
executed
1
by
a
vision
care
provider
and
a
vision
benefit
manager
for
2
the
vision
benefit
manager
to
recover
a
reimbursement
amount
3
from
the
vision
care
provider
shall
be
the
same
period
of
time
4
allowed
or
required
for
a
vision
benefit
manager
to
remit
the
5
applicable
reimbursement
following
a
vision
care
provider’s
6
submission
of
a
clean
claim
for
services
rendered
or
materials
7
furnished.
This
subsection
shall
not
be
construed
to
limit
a
8
vision
benefit
manager’s
ability
to
conduct
an
audit
of
claims,
9
in
accordance
with
the
vision
benefit
plan
manager’s
written
10
policies
and
applicable
law,
if
the
vision
benefit
manager
has
11
a
reasonable
belief
that
the
vision
care
provider
has
engaged
12
in
fraud,
waste,
or
abuse.
13
4.
The
time
frame
for
an
audit
of
a
claim
or
collection
of
a
14
claim
shall
be
equal
for
a
vision
benefit
manager
and
a
vision
15
care
provider.
The
time
frame
for
audit
of
a
claim
shall
be
16
extended
for
the
vision
care
provider
if
the
submission
and
17
claim
correspondence
is
ongoing.
18
5.
A
vision
benefit
manager
shall
reimburse
a
vision
care
19
provider
the
contracted
amount
for
a
covered
service
or
covered
20
material
provided
to
a
covered
person
if
the
covered
person
21
was
verified
to
be
eligible
to
receive
the
covered
service
or
22
covered
material
on
the
date
of
service
by
the
vision
care
23
provider
through
the
customary
verification
methods
of
the
24
vision
benefit
manager.
25
6.
A
vision
benefit
manager
shall
identify
participating
26
vision
care
providers
in
a
neutral
manner
that
does
not
27
distinguish
between
participating
vision
care
providers
based
28
on
any
of
the
following
characteristics:
29
a.
A
discount
or
incentive
offered
by
the
vision
care
30
provider
on
services
and
materials
that
are
not
covered
by
the
31
vision
benefit
manager.
32
b.
The
dollar
amount,
volume
amount,
or
percent
usage
amount
33
of
any
material
purchased
by
the
vision
care
provider.
34
c.
The
brand,
source,
manufacturer,
or
supplier
of
a
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covered
service
or
covered
material
utilized
by
the
vision
care
1
provider.
2
7.
a.
A
vision
benefit
manager
shall
be
licensed
to
conduct
3
the
business
of
insurance
in
this
state,
and
shall
submit
an
4
application
for
licensure
to
the
commissioner
of
insurance
as
5
prescribed
by
the
commissioner
by
rule.
6
b.
A
vision
benefit
manager
shall
comply
with
all
applicable
7
current
procedural
terminology
code
requirements.
8
Sec.
3.
NEW
SECTION
.
514M.3
Prohibited
conduct
——
vision
9
benefit
managers.
10
1.
a.
A
vision
benefit
manager
that
offers
multiple
vision
11
benefit
plans
or
vision
benefit
discount
plans
shall
not
12
require
a
vision
care
provider,
as
a
condition
of
participation
13
in
a
vision
benefit
plan
or
vision
benefit
discount
plan,
14
to
participate
in
the
vision
benefit
manager’s
other
vision
15
benefit
plans
or
vision
benefit
discount
plans.
16
b.
In
addition
to
any
penalties
provided
under
this
chapter,
17
a
violation
of
this
subsection
shall
constitute
a
prohibited
18
practice
or
act
under
section
714H.3.
19
c.
A
contract
in
violation
of
this
subsection
shall
be
void
20
as
a
matter
of
law.
21
2.
A
vision
benefit
manager
shall
not
require
a
vision
care
22
provider
to
do
any
of
the
following:
23
a.
Establish
a
security
interest
in
all
or
part
of
the
24
vision
benefit
manager’s
property
or
assets,
including
assets
25
pertaining
to
the
vision
benefit
manager’s
practice,
in
an
26
amount
equal
to
an
amount
owed
to
a
vision
benefit
manager
upon
27
termination
of
a
contract.
28
b.
Disclose
a
covered
person’s
confidential
or
protected
29
health
information
unless
the
disclosure
is
expressly
30
authorized
by
the
covered
person,
or
permitted
without
31
authorization
under
the
federal
Health
Insurance
Portability
32
and
Accountability
Act
of
1996,
Pub.
L.
No.
104-191,
including
33
amendments
thereto
and
regulations
promulgated
thereunder.
34
c.
Disclose
or
report
a
medical
history
or
diagnosis
as
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a
condition
to
file
a
claim,
adjudicate
a
claim,
or
receive
1
reimbursement
for
a
covered
service.
2
d.
Disclose
or
report
a
covered
person’s
glasses
3
prescription,
contact
lens
prescription,
ophthalmic
device
4
measurements,
facial
photograph,
or
unique
anatomical
5
measurements
as
a
condition
to
file
a
claim,
adjudicate
6
a
claim,
or
receive
reimbursement
for
a
claim,
unless
the
7
information
is
necessary
for
the
vision
benefit
manager
to
8
manufacture,
or
cause
to
be
manufactured,
a
covered
material
9
that
is
submitted
on
the
applicable
claim.
10
e.
Disclose
a
covered
person’s
information,
other
than
11
information
identified
in
the
most
recent
version
of
the
12
national
uniform
claim
committee
health
insurance
claim
form,
13
as
a
condition
to
file
a
claim,
adjudicate
a
claim,
or
receive
14
reimbursement
for
a
claim
unless
the
information
is
necessary
15
for
the
vision
benefit
manager
to
manufacture,
or
cause
to
16
be
manufactured,
a
covered
material
that
is
submitted
on
the
17
applicable
claim.
18
3.
A
vision
benefit
manager
shall
not,
directly
or
19
indirectly,
control
or
attempt
to
control
the
professional
20
judgment,
manner
of
practice,
or
practice
of
a
vision
care
21
provider.
22
4.
A
vision
benefit
manager
shall
not,
directly
or
23
indirectly,
withhold
or
recoup
payment
to
a
vision
care
24
provider
for
a
covered
service
or
covered
material
provided
for
25
a
covered
person
if
the
covered
person
was
shown
to
be
eligible
26
on
the
date
that
the
covered
service
or
covered
material
was
27
provided.
28
5.
A
vision
benefit
manager
shall
not
reimburse
a
vision
29
care
provider
a
different
amount
for
a
covered
service
or
30
covered
material
because
of
the
vision
care
provider’s
choice
31
of
any
of
the
following:
32
a.
Optical
laboratory.
33
b.
Source
or
supplier
of
contact
lenses,
ophthalmic
lenses,
34
ophthalmic
glasses
frames
or
covered
or
noncovered
services
or
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materials.
1
c.
Equipment
used
for
patient
care.
2
d.
Retail
optical
affiliation.
3
e.
Vision
support
organization.
4
f.
Group
purchasing
organization.
5
g.
Doctor
alliance.
6
h.
Professional
trade
association
membership.
7
i.
Electronic
health
record
software,
electronic
medical
8
record
software,
or
practice
management
software.
9
j.
Third-party
claim
filing
service,
billing
service,
or
10
electronic
data
interchange
clearinghouse
company.
11
6.
A
vision
benefit
manager
shall
not,
directly
or
12
indirectly,
restrict,
limit,
or
influence
any
of
the
following:
13
a.
A
vision
care
provider’s
choice
of
electronic
health
14
record
software,
electronic
medical
record
software,
or
15
practice
management
software.
16
b.
A
vision
care
provider’s
choice
of
third-party
claim
17
filing
service,
billing
service,
or
electronic
data
interchange
18
clearinghouse
company.
19
c.
A
vision
care
provider’s
access
to
a
covered
person’s
20
complete
plan
coverage
information,
including
in-network
and
21
out-of-network
coverage
details.
22
7.
A
vision
benefit
manager
shall
not
apply
a
chargeback
to
23
a
covered
person
or
vision
care
provider
if
the
chargeback
is
24
for
a
covered
service
or
covered
material
for
which
the
vision
25
benefit
manager
does
not
incur
the
cost
to
produce,
deliver,
or
26
provide
the
covered
service
or
covered
material
to
the
covered
27
person
or
vision
care
provider.
28
8.
A
vision
benefit
manager
shall
not
require
or
request
29
a
vision
care
provider
to
opt
in
or
opt
out,
or
waive
by
30
contract,
the
requirements
of
this
section
and
section
514M.4.
31
9.
A
vision
benefit
manager
shall
not
do
any
of
the
32
following:
33
a.
Mandate,
or
otherwise
condition,
a
reimbursement
or
34
participation
on
a
price
term
for
a
service
or
material
that
is
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not
a
covered
service
or
covered
material.
1
b.
Direct
or
limit
a
covered
person’s
choice
of
vision
2
care
provider
for
a
service
or
material
that
is
not
a
covered
3
service
or
covered
material.
4
10.
a.
A
vision
benefit
manager
shall
not
engage
in
5
marketing
or
advertising
activities
that
may
be
misleading
6
or
deceptive
to
the
public.
Upon
request
by
an
enforcement
7
agency,
a
vision
benefit
manager
shall
submit
all
information
8
regarding
alleged
savings
and
discounts
offered
by
affiliates
9
of
the
vision
benefit
manager.
10
b.
A
vision
benefit
manager
shall
not
promote
or
use
in
11
any
marketing
or
advertising
that
a
covered
service
or
covered
12
material
is
“free”,
“no
charge”,
or
“complimentary”,
or
any
13
materially
similar
language,
to
a
client,
purchaser,
company,
14
covered
person
or
prospective
covered
person.
15
11.
A
vision
benefit
manager
shall
not
offer
a
covered
16
person
varying
cost
sharing,
coverage
amounts,
rebates,
gift
17
cards,
or
other
incentives
to
obtain
covered
or
noncovered
18
materials
or
services
at
any
of
the
following:
19
a.
A
particular
participating
vision
care
provider.
20
b.
A
retail
establishment
owned
by,
partially
owned
by,
21
contracted
with,
or
otherwise
affiliated
with
the
vision
22
benefit
manager.
23
c.
An
internet
or
virtual
vision
care
provider
or
retailer
24
owned
by,
partially
owned
by,
contracted
with,
or
otherwise
25
affiliated
with
the
vision
benefit
manager.
26
12.
A
vision
benefit
manager
shall
not
retroactively
27
reverse
reimbursement
to
a
vision
care
provider
who
relied
in
28
good
faith
on
a
covered
person’s
presented
coverage
credentials
29
and
the
customary
verification
methods
of
the
vision
benefits
30
manager
if
the
vision
benefit
manager
later
determines
that
the
31
covered
person
was
ineligible
to
receive
covered
services
or
32
covered
materials
on
the
date
of
service.
33
Sec.
4.
NEW
SECTION
.
514M.4
Prohibited
conduct
——
34
contracts.
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1.
A
contract
between
a
vision
benefit
manager
and
a
vision
1
care
provider
shall
not
exceed
a
term
of
two
years
from
the
2
date
that
the
contract
is
fully
executed.
3
2.
A
vision
benefit
manager
shall
not
construe
4
re-credentialing
as
renewing
a
contract
with
a
participating
5
vision
care
provider.
A
vision
care
provider
contract
shall
6
be
a
distinct
and
separate
document
from
any
credentialing
7
materials,
and
shall
be
signed
by
the
vision
care
provider
and
8
the
vision
benefit
manager.
9
3.
A
vision
benefit
manager
shall
include
a
copy
of
a
10
current
plan
provider
manual
referred
to
in
a
vision
care
11
provider
contract
at
the
time
the
contract
is
delivered
to
a
12
vision
care
provider
or
prospective
vision
care
provider.
13
4.
A
contract
entered
into
by
a
vision
benefit
manager
with
14
a
vision
care
provider
shall
not
require
a
vision
care
provider
15
to
do
any
of
the
following:
16
a.
Provide
services
or
materials
at
a
fee
limited
or
set
17
by
the
vision
benefit
manager,
unless
the
service
or
material
18
is
reimbursed
as
a
covered
service
or
covered
material
under
19
the
contract.
20
b.
Consider
applicable
discounts
and
chargebacks
to
provide
21
a
covered
service
or
covered
material
to
a
covered
person
at
22
a
financial
loss.
23
c.
Accept
a
reimbursement
payment
in
the
form
of
a
virtual
24
credit
card
or
any
other
payment
method
wherein
a
processing
25
fee,
administrative
fee,
percentage
amount,
or
dollar
amount
26
is
assessed
for
the
vision
care
provider
to
receive
the
27
reimbursement
payment.
28
d.
Equally
share
the
expenses
of
arbitration.
Each
party
29
shall
bear
the
party’s
own
arbitration
costs,
contingent
upon
a
30
fee-shifting
provision
that
grants
prevailing
party
status.
31
5.
A
contract
entered
into
by
a
vision
benefit
manager
with
32
a
vision
care
provider
shall
not
restrict
or
limit,
either
33
directly
or
indirectly,
the
vision
care
provider’s
choice
34
of,
or
use
of,
a
source
or
supplier
of
covered
or
uncovered
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services
or
materials
provided
to
a
covered
person,
including
1
the
choice
or
use
of
an
optical
laboratory.
2
6.
A
vision
benefit
manager
shall
not
change
or
alter
a
3
contract,
including
any
terms,
reimbursements,
or
fee
schedules
4
contained
in
the
contract,
entered
into
with
a
participating
5
vision
care
provider
unless
the
vision
benefit
manager,
at
6
least
ninety
calendar
days
prior
to
the
effective
date
of
the
7
proposed
change,
does
all
of
the
following:
8
a.
Delivers
a
certified
letter,
or
an
electronic
9
communication
requiring
an
electronic
signature
proving
10
receipt,
to
the
vision
care
provider
detailing
the
proposed
11
change.
12
b.
Upon
request
by
a
vision
care
provider,
the
vision
13
benefit
manager
meets
face-to-face
or
virtually,
to
discuss
the
14
proposed
change
with
the
vision
care
provider.
15
c.
Receives
a
written
agreement
from
the
vision
care
16
provider
approving
the
proposed
change.
If
the
vision
care
17
provider
does
not
agree
in
writing
to
the
proposed
change,
the
18
current
contract
shall
continue
and
the
vision
benefit
manager
19
shall
not
remove
the
vision
care
provider
from
a
network
panel
20
or
plan
as
retaliation
for
not
accepting
the
proposed
change.
21
d.
If
a
vision
benefit
manager
seeks
to
make
three
or
more
22
material
changes
to
an
existing
contract,
the
vision
benefit
23
manager
shall
enter
into
a
new
contract
with
the
vision
care
24
provider.
25
e.
A
proposed
amendment
to
an
existing
contract
between
26
a
vision
benefit
manager
and
a
vision
care
provider
shall
27
be
delivered
to
the
vision
care
provider
for
the
provider’s
28
review.
The
proposed
amendment
shall
be
enumerated
in
a
cover
29
letter
and
clearly
marked
within
the
body
of
the
applicable
30
contract.
31
7.
a.
Except
as
provided
in
this
subsection,
a
vision
32
benefit
manager
shall
not
terminate
a
contract
with
a
vision
33
care
provider
prior
to
the
expiration
of
the
contract.
34
b.
If
a
vision
benefit
manager
believes
that
a
vision
care
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provider
has
breached
a
contract
between
the
vision
benefit
1
manager
and
the
vision
care
provider,
the
vision
benefit
2
manager
shall
provide
written
notice
specifying
the
alleged
3
breach
to
the
vision
care
provider.
If
the
vision
care
4
provider
fails
to
remedy
the
breach
to
the
satisfaction
of
the
5
vision
benefit
manager
within
thirty
calendar
days
of
receipt
6
of
the
written
notice,
the
vision
benefit
manager
may
terminate
7
the
contract
with
the
vision
care
provider.
8
Sec.
5.
NEW
SECTION
.
514M.5
Coordination
of
benefits.
9
1.
A
vision
benefit
manager
shall
comply
with
the
national
10
association
of
insurance
commissioners
coordination
of
benefits
11
regulations.
12
2.
Coordination
of
benefits
shall
allow
for
a
covered
person
13
to
apply
all
the
covered
person’s
benefits
to
the
cost
of
a
14
covered
service
and
covered
material.
15
Sec.
6.
NEW
SECTION
.
514M.6
Vision
benefit
managers
——
16
merger
or
acquisition.
17
For
an
acquisition
or
merger
of
a
vision
benefit
manager,
18
all
parties
to
the
acquisition
or
merger
shall
provide
for
all
19
of
the
following:
20
1.
A
reenrollment
period
for
vision
care
providers.
21
The
reenrollment
process
and
details
must
be
well
defined
22
and
provide
for
a
minimum
of
six
months
notice
to
vision
23
care
providers
prior
to
the
activation
of
a
new
plan
by
24
the
prevailing
vision
benefit
manager
after
the
merger
or
25
acquisition.
26
2.
During
the
merger
or
acquisition,
a
vision
care
provider
27
shall
be
entitled
to
opt
out
of
reenrollment
without
penalty
or
28
obligation
as
provided
in
the
vision
care
provider’s
current
29
contract
with
a
vision
benefit
manager.
30
3.
The
prevailing
vision
benefit
manager
to
the
merger
or
31
acquisition
shall
enter
into
updated
contracts
with
all
vision
32
benefit
providers
who
choose
to
reenroll.
33
Sec.
7.
NEW
SECTION
.
514M.7
Penalties.
34
1.
A
vision
care
provider
adversely
affected
by
a
violation
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of
this
chapter
by
a
vision
benefit
manager
may
bring
an
action
1
in
a
court
of
competent
jurisdiction
for
injunctive
relief
2
against
the
vision
benefit
manager.
3
2.
The
attorney
general
may
bring
an
action
on
behalf
of
4
a
vision
care
provider
for
injunctive
relief
against
a
vision
5
benefit
manager.
6
3.
If
a
vision
care
provider
prevails
in
an
action
under
7
subsection
1,
in
addition
to
injunctive
relief,
the
vision
care
8
provider
shall
be
entitled
to
recover
all
of
the
following:
9
a.
Monetary
damages,
including
but
not
limited
to
direct,
10
indirect,
special,
and
punitive
damages.
11
b.
A
penalty
of
no
more
than
ten
thousand
dollars
for
each
12
violation.
13
c.
Attorney
fees
and
costs.
14
Sec.
8.
NEW
SECTION
.
514M.8
Applicability.
15
1.
This
chapter
shall
apply
to
policies,
contracts,
and
16
plans
between
a
vision
benefit
manager
and
a
vision
care
17
provider
delivered,
issued
for
delivery,
continued,
or
renewed
18
in
this
state
on
or
after
the
effective
date
of
this
Act.
19
2.
This
chapter
shall
apply
to
an
affiliate
or
subcontractor
20
used
by
a
vision
benefit
manager
to
supply
covered
services
21
or
covered
materials
to
a
vision
care
provider
or
a
covered
22
person.
23
Sec.
9.
NEW
SECTION
.
514M.9
Rules.
24
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
25
chapter
17A
to
administer
this
chapter.
26
Sec.
10.
Section
714H.3,
subsection
2,
Code
2026,
is
amended
27
by
adding
the
following
new
paragraph:
28
NEW
PARAGRAPH
.
i.
Section
514M.3,
subsection
1.
29
Sec.
11.
EFFECTIVE
DATE.
This
Act,
being
deemed
of
30
immediate
importance,
takes
effect
upon
enactment.
31
EXPLANATION
32
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
33
the
explanation’s
substance
by
the
members
of
the
general
assembly.
34
This
bill
relates
to
vision
benefit
plans,
vision
benefit
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managers,
vision
care
providers,
and
vision
care
provider
1
contracts.
2
The
bill
details
the
standards
of
conduct
for
vision
3
benefit
managers
(managers),
including
the
requirements
4
for
a
reimbursement
paid
by
a
manager
to
a
vision
care
5
provider
(provider),
annual
increases
in
reimbursement
6
rate
fee
schedules,
the
period
of
time
for
a
manager
to
7
recover
a
reimbursement
amount
from
a
provider,
the
auditing
8
time
frame
for
an
audit
of
a
claim
or
a
collection
of
a
9
claim,
a
reimbursement
for
a
covered
service
or
covered
10
material
provided
to
a
covered
person,
the
identification
of
11
participating
providers,
and
the
licensure
requirements
for
12
managers.
“Covered
person”,
“vision
benefit
manager”,
and
13
“vision
care
provider”
are
defined
in
the
bill.
14
A
manager
shall
not
engage
in
any
of
the
conduct
prohibited
15
by
the
bill.
A
contract
between
a
manager
and
a
provider
shall
16
not
violate
the
provisions
of
the
bill.
17
A
manager
shall
comply
with
the
national
association
of
18
insurance
commissioners
coordination
of
benefits
regulations,
19
and
the
coordination
of
benefits
shall
allow
for
a
covered
20
person
to
apply
all
benefits
to
the
cost
of
a
covered
service
21
and
covered
material.
22
Under
the
bill,
for
the
acquisition
or
merger
of
managers,
23
the
parties
to
the
acquisition
or
merger
shall
provide
for
a
24
reenrollment
period
for
providers.
The
reenrollment
process
25
and
details
must
be
well
defined
and
provide
for
a
minimum
of
26
six
months
notice
to
providers
prior
to
the
activation
of
a
new
27
plan
by
the
prevailing
manager
after
the
merger
or
acquisition.
28
During
the
merger
or
acquisition,
a
provider
shall
be
entitled
29
to
opt
out
of
reenrollment
without
penalty
or
obligation
to
30
the
previous
contract.
The
prevailing
manager
to
the
merger
31
or
acquisition
shall
enter
into
updated
contracts
with
all
32
providers
who
choose
to
reenroll.
33
A
provider
adversely
affected
by
a
violation
of
the
bill
34
by
a
manager
may
bring
an
action
in
a
court
of
competent
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jurisdiction
for
injunctive
relief
against
the
manager.
If
a
1
provider
prevails
in
such
action,
in
addition
to
injunctive
2
relief,
the
provider
shall
be
entitled
to
recover
monetary
3
damages,
penalties
not
to
exceed
$10,000
for
each
violation,
4
and
attorney
fees
and
costs.
The
attorney
general
may
bring
an
5
action
on
behalf
of
a
provider
for
injunctive
relief
against
6
a
manager.
7
The
bill
applies
to
policies,
contracts,
and
plans
between
8
a
manager
and
a
provider
delivered,
issued
for
delivery,
9
continued,
or
renewed
in
this
state
on
or
after
the
effective
10
date
of
the
bill.
The
bill
also
applies
to
an
affiliate
or
11
subcontractor
used
by
a
manager
to
supply
covered
services
or
12
covered
materials
to
a
provider
or
a
covered
person.
13
The
commissioner
of
insurance
may
adopt
rules
to
administer
14
the
bill.
15
The
bill
makes
a
conforming
change
to
Code
section
16
714H.3(2).
17
The
bill
takes
effect
upon
enactment.
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