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House
File
656
-
Introduced
HOUSE
FILE
656
BY
BOSSMAN
A
BILL
FOR
An
Act
relating
to
vision
benefit
plans,
the
regulation
of
1
insurers
and
vision
benefit
managers,
vision
care
providers,
2
and
vision
care
provider
contracts
and
including
effective
3
date
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
an
insurer,
vision
benefit
manager,
or
13
subcontractor
is
provided
to
a
vision
care
provider
by
a
14
covered
person’s
plan
contract,
or
for
which
a
reimbursement
15
would
be
available
but
for
the
application
of
the
covered
16
person’s
cost
sharing,
regardless
of
how
the
materials
are
17
listed
or
described
in
a
covered
person’s
benefit
plan’s
18
definition
of
benefits.
19
4.
“Covered
person”
means
a
policyholder,
subscriber,
20
enrollee,
or
other
individual
participating
in
a
health
benefit
21
plan,
vision
benefit
plan,
or
vision
benefit
discount
plan
22
that
provides
for
third-party
payment
or
prepayment
of
covered
23
services
or
covered
materials.
24
5.
“Covered
service”
means
a
service
performed
by
a
vision
25
care
provider
for
which
reimbursement
from
an
insurer,
vision
26
benefit
manager,
or
subcontractor
is
provided
to
a
vision
care
27
provider
by
a
covered
person’s
plan
contract,
or
for
which
a
28
reimbursement
would
be
available
but
for
the
application
of
the
29
covered
person’s
cost
sharing,
regardless
of
how
the
services
30
are
listed
or
described
in
a
covered
person’s
benefit
plan’s
31
definition
of
benefits.
32
6.
“Health
benefit
plan”
means
a
policy,
contract,
33
certificate,
or
agreement
offered
or
issued
by
an
insurer,
34
a
third-party
administrator,
or
a
subcontractor
to
provide,
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deliver,
arrange
for,
pay
for,
or
reimburse
any
of
the
costs
1
of
health
care
services.
2
7.
“Insurer”
means
an
individual,
company,
organization,
3
managed
care
organization,
group,
or
other
entity
that
operates
4
a
health
benefit
plan.
5
8.
“Material”
means
ophthalmic
devices
including
but
not
6
limited
to
lenses,
devices
containing
lenses,
artificial
7
intraocular
lenses,
ophthalmic
frames
and
other
lens
mounting
8
apparatus,
prisms,
lens
treatments
and
coatings,
contact
9
lenses,
low-vision
devices,
vision
therapy
devices,
and
10
prosthetic
devices
to
correct,
relieve,
or
treat
defects
or
11
abnormal
conditions
of
the
human
eye
or
its
adnexa,
or
any
12
material
allowed
to
be
utilized
by
the
Iowa
board
of
optometry.
13
9.
“Participating
vision
care
provider”
means
a
vision
care
14
provider
that
has
entered
into
a
contractual
agreement
or
other
15
business
relationship
with
an
insurer,
vision
benefit
manager,
16
or
subcontractor
to
provide
covered
services
or
covered
17
materials.
18
10.
“Subcontractor”
means
a
person,
including
but
not
19
limited
to
the
person’s
agents,
servants,
brokers,
wholesalers,
20
distributors,
partially
or
wholly
owned
subsidiaries,
and
21
controlled
organizations,
that
is
contracted
by
the
vision
22
benefit
manager
to
supply
services
or
materials
to
another
23
vision
benefit
manager,
vision
care
provider,
or
covered
person
24
to
execute
or
fulfill
the
health
benefit
plan,
vision
benefit
25
plan,
or
vision
benefit
discount
plan
of
a
vision
benefit
26
manager.
27
11.
“Third-party
administrator”
means
a
person
that
28
provides
services
including
but
not
limited
to
administrative,
29
operational,
regulatory,
human
resource,
compliance,
and
claim
30
adjudication
services
for
an
insurer,
vision
benefit
manager,
31
individual,
company,
organization,
group,
or
other
entity
under
32
a
contract
or
agreement.
33
12.
“Vision
benefit
discount
plan”
means
a
policy,
contract,
34
or
plan
offered
by
a
vision
benefit
manager
to
a
covered
person
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that
exclusively
provides
for
a
discount
for
vision
care
1
services
or
materials.
2
13.
“Vision
benefit
manager”
means
a
person,
including
3
but
not
limited
to
an
insurer,
a
third-party
administrator,
4
or
a
subcontractor,
that
creates,
promotes,
sells,
provides,
5
advertises,
or
administers
an
integrated
or
stand-alone
vision
6
benefit
plan,
vision
benefit
discount
plan,
or
other
insurance
7
policy
or
contract
which
provides
vision
benefits
or
discounts
8
pertaining
to
the
provision
of
covered
services
or
covered
9
materials
to
a
covered
person.
10
14.
“Vision
benefit
plan”
means
a
policy,
contract,
or
11
plan
offered
or
issued
by
a
vision
benefit
manager
to
provide,
12
deliver,
arrange
for,
pay
for,
or
reimburse
any
of
the
costs
of
13
health
care
services
and
vision
care
materials
and
services.
14
15.
“Vision
care
provider”
means
an
optometrist
licensed
15
under
chapter
154,
or
a
person
engaged
in
the
practice
of
16
medicine
and
surgery
or
osteopathic
medicine
and
surgery
17
licensed
under
chapter
148.
18
Sec.
2.
NEW
SECTION
.
514M.2
Standards
of
conduct
——
19
insurers
and
vision
benefit
managers.
20
1.
A
reimbursement
paid
by
an
insurer
or
vision
benefit
21
manager
for
a
covered
service
or
covered
material
shall
be
22
clearly
and
individually
listed
on
a
reimbursement
schedule
23
made
available
to
the
vision
care
provider,
and
shall
not
24
discriminate
in
the
amount
of
reimbursement
between
physicians,
25
as
that
term
is
defined
under
section
135.1,
as
follows:
26
a.
At
the
time
a
contract
is
offered
to
the
vision
care
27
provider
by
an
insurer
or
vision
benefit
manager.
28
b.
Within
five
business
days
from
the
date
a
contract
is
29
requested
of
the
insurer
or
vision
benefit
manager
by
the
30
participating
vision
care
provider.
31
2.
An
insurer
and
vision
benefit
manager
shall
calculate
an
32
annual
adjustment
using
the
increase,
if
any,
in
the
consumer
33
price
index
for
all
urban
consumers
for
the
most
recent
34
available
five-year
period
published
by
the
United
States
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department
of
labor,
bureau
of
labor
statistics,
and
shall
1
ensure
that
all
contractually
allowed
amounts
and
reimbursement
2
rates
reflect
such
increase.
3
3.
The
period
of
time,
prescribed
by
a
contract
between
a
4
vision
care
provider
and
either
an
insurer
or
vision
benefit
5
manager,
for
the
insurer
or
vision
benefit
manager
to
recover
6
a
reimbursement
amount
from
a
vision
care
provider
shall
be
7
the
same
period
of
time
allowed
or
required
for
an
insurer
or
8
vision
benefit
manager
to
remit
the
applicable
reimbursement
9
following
a
vision
care
provider’s
submission
of
a
clean
claim
10
for
services
rendered
or
materials
furnished.
This
subsection
11
shall
not
be
construed
to
limit
an
insurer’s
or
vision
benefit
12
manager’s
ability
to
conduct
an
audit
of
claims,
in
accordance
13
with
the
insurer’s
or
vision
benefit
plan
manager’s
written
14
policies
and
applicable
law,
if
the
insurer
or
vision
benefit
15
manager
has
a
reasonable
belief
that
the
vision
care
provider
16
has
engaged
in
fraud,
waste,
or
abuse.
17
4.
The
time
frame
for
an
audit
of
a
claim
or
collection
of
18
a
claim
shall
be
equal
for
an
insurer,
vision
benefit
manager,
19
and
a
vision
care
provider.
The
time
frame
for
audit
of
a
20
claim
shall
be
extended
for
the
vision
care
provider
if
the
21
submission
and
claim
correspondence
is
ongoing.
22
5.
An
insurer
or
vision
benefit
manager
shall
reimburse
23
a
vision
care
provider
the
contracted
amount
for
a
covered
24
service
or
covered
material
provided
to
a
covered
person
if
the
25
covered
person
was
verified
to
be
eligible
by
the
vision
care
26
provider
through
customary
verification
methods
of
the
insurer
27
or
vision
benefit
manager
to
receive
the
covered
service
or
28
covered
material
on
the
date
of
service.
29
6.
An
insurer
or
vision
benefit
manager
shall
identify
30
participating
vision
care
providers
in
a
neutral
manner,
31
which
does
not
distinguish
between
participating
vision
care
32
providers
based
on
any
of
the
following
characteristics:
33
a.
A
discount
or
incentive
offered
by
the
vision
care
34
provider
on
services
and
materials
that
are
not
covered
by
the
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insurer
or
vision
benefit
manager.
1
b.
The
dollar
amount,
volume
amount,
or
percent
usage
amount
2
of
any
material
purchased
by
the
vision
care
provider.
3
c.
The
brand,
source,
manufacturer,
or
supplier
of
a
4
covered
service
or
covered
material
utilized
by
the
vision
care
5
provider.
6
7.
a.
A
vision
benefit
manager
shall
be
licensed
to
conduct
7
the
business
of
insurance
in
this
state,
and
shall
submit
an
8
application
for
licensure
to
the
commissioner
of
insurance
as
9
prescribed
by
the
commissioner
by
rule.
10
b.
A
vision
benefit
manager
shall
comply
with
all
applicable
11
current
procedural
terminology
code
requirements.
12
Sec.
3.
NEW
SECTION
.
514M.3
Prohibited
conduct
——
insurers
13
and
vision
benefit
managers.
14
1.
a.
An
insurer
or
vision
benefit
manager
that
offers
15
multiple
vision
benefit
plans
or
vision
benefit
discount
plans
16
shall
not
require
a
vision
care
provider,
as
a
condition
of
17
participation
in
a
vision
benefit
plan
or
vision
benefit
18
discount
plan,
to
participate
in
the
insurer’s
or
vision
19
benefit
manager’s
other
vision
benefit
plans
or
vision
benefit
20
discount
plans.
21
b.
In
addition
to
any
penalties
provided
under
this
chapter,
22
a
violation
of
this
subsection
shall
constitute
a
prohibited
23
practice
or
act
under
section
714H.3.
24
c.
A
contract
in
violation
of
this
subsection
shall
be
void
25
as
a
matter
of
law.
26
2.
An
insurer
or
vision
benefit
manager
shall
not
require
a
27
vision
care
provider
to
do
any
of
the
following:
28
a.
Establish
a
security
interest
in
all
or
part
of
the
29
insurer’s
or
vision
benefit
manager’s
property
or
assets,
30
including
assets
pertaining
to
the
insurer’s
or
vision
benefit
31
manager’s
practice,
in
an
amount
equal
to
an
amount
owed
to
32
an
insurer
or
vision
benefit
manager
upon
termination
of
a
33
contract.
34
b.
Disclose
a
covered
person’s
confidential
or
protected
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health
information
unless
the
disclosure
is
expressly
1
authorized
by
the
covered
person,
or
permitted
without
2
authorization
under
the
federal
Health
Insurance
Portability
3
and
Accountability
Act
of
1996,
Pub.
L.
No.
104-191,
including
4
amendments
thereto
and
regulations
promulgated
thereunder.
5
c.
Disclose
or
report
a
medical
history
or
diagnosis
as
6
a
condition
to
file
a
claim,
adjudicate
a
claim,
or
receive
7
reimbursement
for
a
covered
service.
8
d.
Disclose
or
report
a
covered
person’s
glasses
9
prescription,
contact
lens
prescription,
ophthalmic
device
10
measurements,
facial
photograph,
or
unique
anatomical
11
measurements
as
a
condition
to
file
a
claim,
adjudicate
12
a
claim,
or
receive
reimbursement
for
a
claim,
unless
the
13
information
is
necessary
for
the
vision
benefit
manager
to
14
manufacture,
or
cause
to
be
manufactured,
a
covered
material
15
that
is
submitted
on
the
applicable
claim.
16
e.
Disclose
a
covered
person’s
information,
other
than
17
information
identified
in
the
most
recent
version
of
the
18
national
uniform
claim
committee
health
insurance
claim
form,
19
as
a
condition
to
file
a
claim,
adjudicate
a
claim,
or
receive
20
reimbursement
for
a
claim
unless
the
information
is
necessary
21
for
the
vision
benefit
manager
to
manufacture,
or
cause
to
22
be
manufactured,
a
covered
material
that
is
submitted
on
the
23
applicable
claim.
24
3.
An
insurer
or
vision
benefit
manager
shall
not,
directly
25
or
indirectly,
control
or
attempt
to
control
the
professional
26
judgment,
manner
of
practice,
or
practice
of
a
vision
care
27
provider.
28
4.
An
insurer
or
vision
benefit
manager
shall
not,
directly
29
or
indirectly,
withhold
or
recoup
payment
to
a
vision
care
30
provider
for
a
covered
service
or
covered
material
provided
for
31
a
covered
person
if
the
covered
person
was
shown
to
be
eligible
32
on
the
date
that
the
covered
service
or
covered
material
was
33
provided.
34
5.
An
insurer
or
vision
benefit
manager
shall
not
reimburse
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a
vision
care
provider
a
different
amount
for
a
covered
service
1
or
covered
material
because
of
the
vision
care
provider’s
2
choice
of
any
of
the
following:
3
a.
Optical
laboratory.
4
b.
Source
or
supplier
of
contact
lenses,
ophthalmic
lenses,
5
ophthalmic
glasses
frames
or
covered
or
noncovered
services
or
6
materials.
7
c.
Equipment
used
for
patient
care.
8
d.
Retail
optical
affiliation.
9
e.
Vision
support
organization.
10
f.
Group
purchasing
organization.
11
g.
Doctor
alliance.
12
h.
Professional
trade
association
membership.
13
i.
Electronic
health
record
software,
electronic
medical
14
record
software,
or
practice
management
software.
15
j.
Third-party
claim
filing
service,
billing
service,
or
16
electronic
data
interchange
clearinghouse
company.
17
6.
An
insurer
or
vision
benefit
manager
shall
not,
directly
18
or
indirectly,
restrict,
limit,
or
influence
any
of
the
19
following:
20
a.
A
vision
care
provider’s
choice
of
electronic
health
21
record
software,
electronic
medical
record
software,
or
22
practice
management
software.
23
b.
A
vision
care
provider’s
choice
of
third-party
claim
24
filing
service,
billing
service,
or
electronic
data
interchange
25
clearinghouse
company.
26
c.
A
vision
care
provider’s
access
to
a
covered
person’s
27
complete
plan
coverage
information,
including
in-network
and
28
out-of-network
coverage
details.
29
7.
An
insurer
or
vision
benefit
manager
shall
not
apply
a
30
chargeback
to
a
covered
person
or
vision
care
provider
if
the
31
chargeback
is
for
a
covered
service
or
covered
material
for
32
which
the
insurer
or
vision
benefit
manager
does
not
incur
the
33
cost
to
produce,
deliver,
or
provide
the
covered
service
or
34
covered
material
to
the
covered
person
or
vision
care
provider.
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nls/ko
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656
8.
An
insurer
or
vision
benefit
manager
shall
not
require
or
1
request
a
vision
care
provider
to
opt
in
or
opt
out,
or
waive
by
2
contract,
the
requirements
of
this
section
and
section
514M.4.
3
9.
An
insurer
or
vision
benefit
manager
shall
not
do
any
of
4
the
following:
5
a.
Mandate,
or
otherwise
condition,
a
reimbursement
or
6
participation
on
a
price
term
for
a
service
or
material
that
is
7
not
a
covered
service
or
covered
material.
8
b.
Direct
or
limit
a
covered
person’s
choice
of
vision
9
care
provider
for
a
service
or
material
that
is
not
a
covered
10
service
or
covered
material.
11
10.
a.
An
insurer
or
vision
benefit
manager
shall
not
12
engage
in
marketing
or
advertising
activities
that
may
be
13
misleading
or
deceptive
to
the
public.
Upon
request
by
an
14
enforcement
agency,
an
insurer
and
vision
benefit
manager
shall
15
submit
all
information
regarding
alleged
savings
and
discounts
16
offered
by
affiliates
of
the
insurer
or
vision
benefit
manager.
17
b.
An
insurer
or
vision
benefit
manager
shall
not
promote
or
18
use
in
any
marketing
or
advertising
that
a
covered
service
or
19
covered
material
is
“free”,
“no
charge”,
or
“complimentary”,
20
or
any
materially
similar
language,
to
a
client,
purchaser,
21
company,
covered
person
or
prospective
covered
person.
22
11.
An
insurer
or
vision
benefit
manager
shall
not
offer
a
23
covered
person
varying
cost
sharing,
coverage
amounts,
rebates,
24
gift
cards,
or
other
incentives
to
obtain
covered
or
noncovered
25
materials
or
services
at
any
of
the
following:
26
a.
A
particular
participating
vision
care
provider.
27
b.
A
retail
establishment
owned
by,
partially
owned
by,
28
contracted
with,
or
otherwise
affiliated
with
the
vision
29
benefit
manager.
30
c.
An
internet
or
virtual
vision
care
provider
or
retailer
31
owned
by,
partially
owned
by,
contracted
with,
or
otherwise
32
affiliated
with
the
vision
benefit
manager.
33
12.
An
insurer
or
vision
benefit
manager
shall
not
34
retroactively
reverse
reimbursement
to
a
vision
care
provider
35
-8-
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2470HH
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656
who
relied
in
good
faith
on
a
covered
person’s
presented
1
coverage
credentials
and
the
customary
verification
methods
of
2
the
insurer
or
vision
benefits
manager,
if
the
vision
benefit
3
manager
later
determines
that
the
covered
person
was
ineligible
4
to
receive
covered
services
or
covered
materials
on
the
date
5
of
service.
6
Sec.
4.
NEW
SECTION
.
514M.4
Prohibited
conduct
——
7
contracts.
8
1.
A
contract
between
an
insurer
or
vision
benefit
manager
9
and
a
vision
care
provider
shall
not
exceed
a
term
of
two
years
10
from
the
date
that
the
contract
is
fully
executed.
11
2.
An
insurer
or
vision
benefit
manager
shall
not
construe
12
re-credentialing
as
renewing
a
contract
with
a
participating
13
vision
care
provider.
A
vision
care
provider
contract
shall
14
be
a
distinct
and
separate
document
from
any
credentialing
15
materials,
and
shall
be
signed
by
the
vision
care
provider
and
16
the
insurer
or
vision
benefit
manager.
17
3.
An
insurer
or
vision
benefit
manager
shall
include
a
copy
18
of
a
current
plan
provider
manual
referred
to
in
a
vision
care
19
provider
contract
at
the
time
the
contract
is
delivered
to
a
20
vision
care
provider
or
prospective
vision
care
provider.
21
4.
A
contract
entered
into
by
an
insurer
or
vision
benefit
22
manager
with
a
vision
care
provider
shall
not
require
a
vision
23
care
provider
to
do
any
of
the
following:
24
a.
Provide
services
or
materials
at
a
fee
limited
or
set
25
by
the
vision
benefit
manager,
unless
the
service
or
material
26
is
reimbursed
as
a
covered
service
or
covered
material
under
27
the
contract.
28
b.
Consider
applicable
discounts
and
chargebacks
to
provide
29
a
covered
service
or
covered
material
to
a
covered
person
at
30
a
financial
loss.
31
c.
Accept
a
reimbursement
payment
in
the
form
of
a
virtual
32
credit
card
or
any
other
payment
method
wherein
a
processing
33
fee,
administrative
fee,
percentage
amount,
or
dollar
amount
34
is
assessed
for
the
vision
care
provider
to
receive
the
35
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656
reimbursement
payment.
1
d.
Equally
share
the
expenses
of
arbitration.
Each
party
2
shall
bear
the
party’s
own
arbitration
costs,
contingent
upon
a
3
fee-shifting
provision
that
grants
prevailing
party
status.
4
5.
A
contract
entered
into
by
an
insurer
or
vision
benefit
5
manager
with
a
vision
care
provider
shall
not
restrict
6
or
limit,
either
directly
or
indirectly,
the
vision
care
7
provider’s
choice
of,
or
use
of,
a
source
or
supplier
of
8
covered
or
uncovered
services
or
materials
provided
to
a
9
covered
person,
including
the
choice
or
use
of
an
optical
10
laboratory.
11
6.
An
insurer
or
vision
benefit
manager
shall
not
change
12
or
alter
a
contract,
including
any
terms,
reimbursements,
or
13
fee
schedules
contained
in
the
contract,
entered
into
with
14
a
participating
vision
care
provider
unless
the
insurer
or
15
vision
benefit
manager,
at
least
ninety
calendar
days
prior
16
to
the
effective
date
of
the
proposed
change,
does
all
of
the
17
following:
18
a.
Delivers
a
certified
letter,
or
an
electronic
19
communication
requiring
an
electronic
signature
proving
20
receipt,
to
the
vision
care
provider
detailing
the
proposed
21
change.
22
b.
Upon
request
by
a
vision
care
provider,
the
insurer
or
23
vision
benefit
manager
meets
face-to-face
or
virtually,
to
24
discuss
the
proposed
change
with
the
vision
care
provider.
25
c.
Receives
a
written
agreement
from
the
vision
care
26
provider
approving
the
proposed
change.
If
the
vision
care
27
provider
does
not
agree
in
writing
to
the
proposed
change,
28
the
current
contract
shall
continue
and
the
insurer
or
vision
29
benefit
manager
shall
not
remove
the
vision
care
provider
from
30
a
network
panel
or
plan
as
retaliation
for
not
accepting
the
31
proposed
change.
32
d.
If
an
insurer
or
vision
benefit
manager
seeks
to
make
33
three
or
more
material
changes
to
an
existing
contract,
the
34
insurer
or
vision
benefit
manager
shall
enter
into
a
new
35
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656
contract
with
the
vision
care
provider.
1
e.
A
proposed
amendment
to
an
existing
contract
between
an
2
insurer
or
vision
benefit
manager
and
a
vision
care
provider
3
shall
be
delivered
to
the
vision
care
provider
for
the
4
provider’s
review.
The
proposed
amendment
shall
be
enumerated
5
in
a
cover
letter
and
clearly
marked
within
the
body
of
the
6
applicable
contract.
7
7.
a.
Except
as
provided
in
this
subsection,
an
insurer
or
8
vision
benefit
manager
shall
not
terminate
a
contract
with
a
9
vision
care
provider
prior
to
the
expiration
of
the
contract.
10
b.
If
an
insurer
or
vision
benefit
manager
believes
that
11
a
vision
care
provider
has
breached
a
contract
between
either
12
the
insurer
or
vision
benefit
manager
and
the
vision
care
13
provider,
the
insurer
or
vision
benefit
manager
shall
provide
14
written
notice
specifying
the
alleged
breach
to
the
vision
care
15
provider.
If
the
vision
care
provider
fails
to
remedy
the
16
breach
to
the
satisfaction
of
the
insurer
or
vision
benefit
17
manager
within
thirty
calendar
days
of
receipt
of
the
written
18
notice,
the
insurer
or
vision
benefit
manager
may
terminate
the
19
contract
with
the
vision
care
provider.
20
Sec.
5.
NEW
SECTION
.
514M.5
Coordination
of
benefits.
21
1.
An
insurer
and
a
vision
benefit
manager
shall
comply
22
with
the
national
association
of
insurance
commissioners
23
coordination
of
benefits
regulations.
24
2.
Coordination
of
benefits
shall
allow
for
a
covered
person
25
to
apply
all
the
covered
person’s
benefits
to
the
cost
of
a
26
covered
service
and
covered
material.
27
Sec.
6.
NEW
SECTION
.
514M.6
Insurers
or
vision
benefit
28
managers
——
merger
or
acquisition.
29
For
an
acquisition
or
merger
of
an
insurer
and
a
vision
30
benefit
manager,
all
parties
to
the
acquisition
or
merger
shall
31
provide
for
all
of
the
following:
32
1.
A
reenrollment
period
for
vision
care
providers.
The
33
reenrollment
process
and
details
shall
be
well
defined
and
34
shall
provide
for
a
minimum
of
six
months
notice
to
vision
35
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656
care
providers
prior
to
the
activation
of
a
new
plan
by
the
1
prevailing
entity
after
the
merger
or
acquisition.
2
2.
During
the
merger
or
acquisition,
a
vision
care
provider
3
shall
be
entitled
to
opt
out
of
reenrollment
without
penalty
or
4
obligation
as
provided
in
the
vision
care
provider’s
current
5
contract
with
either
an
insurer
or
a
vision
benefit
manager.
6
3.
The
prevailing
entity
to
the
merger
or
acquisition
shall
7
enter
into
updated
contracts
with
all
vision
benefit
providers
8
who
choose
to
reenroll.
9
Sec.
7.
NEW
SECTION
.
514M.7
Penalties.
10
1.
A
vision
care
provider
adversely
affected
by
a
violation
11
of
this
chapter
by
an
insurer
or
vision
benefit
manager
12
may
bring
an
action
in
a
court
of
competent
jurisdiction
13
for
injunctive
relief
against
the
insurer
or
vision
benefit
14
manager.
15
2.
The
attorney
general
may
bring
an
action
on
behalf
of
a
16
vision
care
provider
for
injunctive
relief
against
an
insurer
17
or
vision
benefit
manager.
18
3.
If
a
vision
care
provider
prevails
in
an
action
under
19
subsection
1,
in
addition
to
injunctive
relief,
the
vision
care
20
provider
shall
be
entitled
to
recover
all
of
the
following:
21
a.
Monetary
damages,
including
but
not
limited
to
direct,
22
indirect,
special,
and
punitive
damages.
23
b.
A
penalty
of
no
more
than
ten
thousand
dollars
for
each
24
violation.
25
c.
Attorney
fees
and
costs.
26
Sec.
8.
NEW
SECTION
.
514M.8
Applicability.
27
1.
This
chapter
shall
apply
to
policies,
contracts,
and
28
plans
between
an
insurer
or
vision
benefit
manager
and
a
vision
29
care
provider
delivered,
issued
for
delivery,
continued,
or
30
renewed
in
this
state
on
or
after
the
effective
date
of
this
31
Act.
32
2.
This
chapter
shall
apply
to
an
affiliate
or
subcontractor
33
used
by
an
insurer
or
vision
benefit
manager
to
supply
covered
34
services
or
covered
materials
to
a
vision
care
provider
or
a
35
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656
covered
person.
1
Sec.
9.
NEW
SECTION
.
514M.9
Rules.
2
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
3
chapter
17A
to
administer
this
chapter.
4
Sec.
10.
Section
714H.3,
subsection
2,
Code
2025,
is
amended
5
by
adding
the
following
new
paragraph:
6
NEW
PARAGRAPH
.
h.
Section
514M.3,
subsection
1.
7
Sec.
11.
EFFECTIVE
DATE.
This
Act,
being
deemed
of
8
immediate
importance,
takes
effect
upon
enactment.
9
EXPLANATION
10
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
11
the
explanation’s
substance
by
the
members
of
the
general
assembly.
12
This
bill
relates
to
vision
benefit
plans,
the
regulation
of
13
insurers
and
vision
benefit
managers,
vision
care
providers,
14
and
vision
care
provider
contracts.
15
The
bill
details
the
standards
of
conduct
for
insurers
16
and
vision
benefit
managers
(managers),
including
the
17
requirements
for
a
reimbursement
paid
by
an
insurer
or
manager
18
to
a
vision
care
provider
(provider),
the
calculation
of
19
an
annual
adjustment,
the
period
of
time
for
an
insurer
or
20
manager
to
recover
a
reimbursement
amount
from
a
provider,
the
21
auditing
time
frame
for
an
audit
of
a
claim
or
a
collection
22
of
a
claim,
a
reimbursement
for
a
covered
service
or
covered
23
material
provided
to
a
covered
person,
the
identification
24
of
participating
providers,
and
the
licensure
requirements
25
for
managers.
“Covered
person”,
“insurer”,
“vision
benefit
26
manager”,
and
“vision
care
provider”
are
defined
in
the
bill.
27
An
insurer
or
manager
shall
not
engage
in
any
of
the
conduct
28
prohibited
by
the
bill.
A
contract
between
an
insurer
or
29
manager
and
a
provider
shall
not
violate
the
provisions
of
the
30
bill.
31
An
insurer
and
a
manager
shall
comply
with
the
national
32
association
of
insurance
commissioners
coordination
of
benefits
33
regulations,
and
the
coordination
of
benefits
shall
allow
for
a
34
covered
person
to
apply
all
benefits
to
the
cost
of
a
covered
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service
and
covered
material.
1
Under
the
bill,
for
the
acquisition
or
merger
of
insurers
2
and
managers,
the
parties
to
the
acquisition
or
merger
3
shall
provide
for
a
reenrollment
period
for
providers.
The
4
reenrollment
process
and
details
shall
be
well
defined
and
5
shall
provide
for
a
minimum
of
six
months
notice
to
providers
6
prior
to
the
activation
of
a
new
plan
by
the
prevailing
7
entity
after
the
merger
or
acquisition.
During
the
merger
8
or
acquisition,
a
provider
shall
be
entitled
to
opt
out
of
9
reenrollment
without
penalty
or
obligation
to
the
previous
10
contract.
The
prevailing
entity
to
the
merger
or
acquisition
11
shall
enter
into
updated
contracts
with
all
providers
who
12
choose
to
reenroll.
13
A
provider
adversely
affected
by
a
violation
of
the
bill
14
by
an
insurer
or
manager
may
bring
an
action
in
a
court
of
15
competent
jurisdiction
for
injunctive
relief
against
the
16
insurer
or
manager.
If
a
provider
prevails
in
such
action,
in
17
addition
to
injunctive
relief,
the
provider
shall
be
entitled
18
to
recover
monetary
damages,
penalties
not
to
exceed
$10,000
19
for
each
violation,
and
attorney
fees
and
costs.
The
attorney
20
general
may
bring
an
action
on
behalf
of
a
provider
for
21
injunctive
relief
against
an
insurer
or
manager.
22
The
bill
applies
to
policies,
contracts,
and
plans
between
23
an
insurer
or
manager
and
a
provider
delivered,
issued
for
24
delivery,
continued,
or
renewed
in
this
state
on
or
after
25
the
effective
date
of
the
bill.
The
bill
also
applies
to
an
26
affiliate
or
subcontractor
used
by
an
insurer
or
manager
to
27
supply
covered
services
or
covered
materials
to
a
provider
or
28
a
covered
person.
29
The
commissioner
of
insurance
may
adopt
rules
to
administer
30
the
bill.
31
The
bill
makes
a
conforming
change
to
Code
section
32
714H.3(2).
33
The
bill
takes
effect
upon
enactment.
34
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