Health Insurance - Vision Benefits - Regulation of Insurers and Vision Benefit Managers

EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
*hb1603*

HOUSE BILL 1603
J5 6lr3675
CF SB 795
By: Delegate S. Johnson
Introduced and read first time: February 16, 2026
Assigned to: Rules and Executive Nominations

A BILL ENTITLED

AN ACT concerning 1

Health Insurance – Vision Benefits – Regulation of Insurers and Vision Benefit 2
Managers 3

FOR the purpose of establishing requirements for certain vision benefits, vision benefit 4
plans, and vision discount plans; requiring an insurer or a vision benefit manager to 5
disclose certain information on its website and in certain communications and 6
maintain certain methods of communication for use by participating eye care 7
providers; establishing certain requirements and prohibitions for contracts between 8
insurers or vision benefit managers and participating eye care providers; 9
establishing procedures f or inclusion and credentialing of participating eye care 10
providers in health benefit plans, vision benefit plans, or vision benefit discount 11
plans; requiring an insurer or a vision benefit manager to comply with certain 12
procedures before amending a provide r agreement; establishing requirements for 13
reimbursement of participating eye care providers by an insurer or a vision benefit 14
manager; and generally relating to eye care providers and health benefit plans, 15
vision benefit plans, and vision benefit discount plans. 16

BY repealing 17
Article – Insurance 18
Section 15–112.2(h) 19
Annotated Code of Maryland 20
(2017 Replacement Volume and 2025 Supplement) 21

BY adding to 22
Article – Insurance 23
Section 15–2201 through 15–2213 to be under the new subtitle “Subtitle 22. Vision 24
Benefits, Vision Benefit Plans, and Vision Benefit Discount Plans” 25
Annotated Code of Maryland 26
(2017 Replacement Volume and 2025 Supplement) 27

2 HOUSE BILL 1603

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 1
That the Laws of Maryland read as follows: 2

Article – Insurance 3

15–112.2. 4

[(h) (1) In this subsection, “covered services” means health care services that 5
are reimbursable under a policy or contract for vision services between an enrollee and a 6
carrier, subject to any contractual limitations on b enefits, including deductibles, 7
copayments, or frequency limitations. 8

(2) A carrier may not include in a vision provider contract a provision that 9
requires a vision provider: 10

(i) to provide health care services that are not covered services at a 11
fee set by the carrier; or 12

(ii) to provide discounts on materials that are not covered benefits. 13

(3) (i) A carrier may not include in a vision provider contract a 14
provision that requires a vision provider, as a condition of participation in a fee–for–service 15
vision provider panel, to participate in a capitated vision provider panel. 16

(ii) Notwithstanding subparagraph (i) of this paragraph, a vision 17
provider contract may contain a provision that requires a vision provider, as a condition of 18
participating in a non –HMO vision provider panel or an HMO vision provider panel to 19
participate in a managed care organization.] 20

SUBTITLE 22. VISION BENEFITS, VISION BENEFIT PLANS, AND VISION BENEFIT 21
DISCOUNT PLANS. 22

15–2201. 23

(A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE TH E MEANINGS 24
INDICATED. 25

(B) “EYE CARE PROVIDER” MEANS AN INDIVIDUAL LICENSED TO PRACTICE 26
OPTOMETRY UNDER TITLE 11 OF THE HEALTH OCCUPATIONS ARTICLE OR AN 27
INDIVIDUAL LICENSED TO PRACTICE MEDICINE UNDER TITLE 14 OF THE HEALTH 28
OCCUPATIONS ARTICLE. 29

(C) “VISION BENEFIT DISCOUNT PLAN” MEANS A POLICY, A CONTRACT, OR 30
AN AGREEMENT OFFERED BY AN INSURER OR A V ISION BENEFIT MANAGE R THAT 31
SOLELY PROVIDES FOR A DISCOUNT FOR VISION CARE SERVICES OR MATERIALS. 32
HOUSE BILL 1603 3

(D) (1) “VISION BENEFIT MANAGE R” MEANS A PERSON THAT , TO THE 1
EXTENT THAT THE PERS ON IS ACTING FOR AN INSURER OR A VISION BENEFIT 2
DISCOUNT PLAN, HAS: 3

(I) CONTROL OVER OR CUST ODY OF PREMIUMS , 4
CONTRIBUTIONS, OR ANY OTHER MONEY O N BEHALF OF AN INSUR ER OR A VISION 5
BENEFIT DISCOUNT PLAN OR WITH RESPECT TO A PLAN, FOR ANY PERIOD OF TIME; 6
OR 7

(II) DISCRETIONARY AUTHOR ITY OVER THE ADJUSTM ENT, 8
PAYMENT, OR SETTLEMENT OF BEN EFIT CLAIMS ON BEHAL F OF AN INSURER OR A 9
VISION BENEFIT PLAN, OR OVER THE INVESTMENT OF THE ASSETS OF AN INSURER 10
OR A VISION BENEFIT PLAN. 11

(2) “VISION BENEFIT MANAGER” DOES NOT INCLUDE A PERSON THAT, 12
WITH RESPECT TO A PA RTICULAR HEALTH BENE FIT PLAN, VISION BENEFIT PLAN , 13
OR VISION BENEFIT DISCOUNT PLAN: 14

(I) IS, OR IS AN EMPLOYEE , AN INSURANCE PRODUCE R, OR A 15
MANAGING GENERA L AGENT OF , AN INSURER OR A VISI ON BENEFIT PLAN THAT 16
INSURES OR ADMINISTERS THE PLAN; OR 17

(II) IS AN INSURANCE PROD UCER THAT SOLICITS , PROCURES, 18
OR NEGOTIATES A PLAN FOR A PLAN SPONSOR A ND HAS NO AUTHORITY OVER THE 19
ADJUSTMENT, PAYMENT, OR SETTLEMENT OF BENEFIT CLAIMS UNDER THE PLAN OR 20
OVER THE INVESTMENT OR HANDLING OF THE PLAN’S ASSETS. 21

(E) “VISION BENEFIT PLAN ” MEANS A POLICY , A CONTRACT , OR AN 22
AGREEMENT OFFERED BY AN INSURER OR A VISI ON BENEFIT MANAGER T O AN 23
ENROLLEE TO PAY FOR, REIMBURSE, OR OFFSET HEALTH AND VISION CARE COSTS. 24

15–2202. 25

THIS SUBTITLE APPLIES ONLY TO AN INSURER OR VISION BENEFIT MANAGER 26
THAT ISSUES, SELLS, OR DELIVERS IN THE STATE A VISION BENEFIT PLAN OR VISION 27
BENEFIT DISCOUNT PLAN OR PROVIDES COVERAGE FOR VISION–RELATED SERVICES 28
UNDER A HEALTH BENEFIT PLAN. 29

15–2203. 30

(A) EACH INSURER AND VISI ON BENEFIT MANAGER S HALL PROVIDE A 31
DISCLOSURE ON ITS WE BSITE AND GENERATE A DOCUMENT CONTAINING THE 32
4 HOUSE BILL 1603

FOLLOWING INFORMATION: 1

(1) THE LEGAL NAME AND E NTITY TYPE OF THE IN SURER OR VISION 2
BENEFIT MANAGER; 3

(2) THE LEGAL ADDRESS OF THE INSURER OR VISIO N BENEFIT 4
MANAGER; 5

(3) THE STATE IN WHICH THE INSURER OR VISION BENEFIT MANAGER 6
WAS FORMED OR ORGANIZED; 7

(4) THE PHYSICAL ADDRESS , MAILING ADDRESS , E–MAIL ADDRESS , 8
AND TELEPHONE NUMBER OF THE HEADQUARTERS OF THE INSURER OR VI SION 9
BENEFIT MANAGER; 10

(5) (I) A LIST OF THE STATE AGENCIES WITH R EGULATORY 11
AUTHORITY OVER THE INSURER OR VISION BENEFIT MANAGER; OR 12

(II) IF THERE IS NO STATE AGENCY WITH REG ULATORY 13
AUTHORITY OVER THE INSURER OR VISION BENEFIT MANAGER, A STATEMENT THAT 14
NO REGULATORY AUTHOR ITY EXISTS OVER THE INSURER OR VISION BE NEFIT 15
MANAGER; 16

(6) THE NAMES, PHYSICAL ADDRESSES, MAILING ADDRESSES, E–MAIL 17
ADDRESSES, AND TELEPHONE NUMBER S OF ALL PARENT COMP ANIES, RELATED 18
HOLDING COMPANIES, AND WHOLLY OR PARTIA LLY OWNED SUBSIDIARY 19
COMPANIES; 20

(7) A LIST OF ALL FEDERA L AND STATE LITIGATION TO W HICH THE 21
COMPANY HAS BEEN A PARTY IN THE IMMEDIATELY PRECEDING 5 YEARS; AND 22

(8) ALL FORMAL COMPLAINTS SUBMITTED TO THE ADMINISTRATION 23
AGAINST THE INSURER OR VISION BENEFIT MA NAGER IN THE IMMEDIA TELY 24
PRECEDING 5 YEARS BY A PURCHASER, AN ENROLLEE, OR AN EYE CARE PROVIDER. 25

(B) THE DISCLOSURE REQUIRED UNDER SUBSECTION (A) OF THIS SECTION 26
SHALL BE: 27

(1) WRITTEN IN PLAIN LANGUAGE; 28

(2) DISPLAYED IN AT LEAST 10 POINT FONT; 29

(3) PROMINENTLY DISPLAYED ON A PUBLICLY ACCE SSIBLE SECTION 30
HOUSE BILL 1603 5

OF THE INSURER ’S OR VISION BENEFIT MANAGER’S WEBSITE TITLED “REQUIRED 1
TRANSPARENCY INFORMATION FOR PATIENTS, DOCTORS, AND PURCHASERS”; AND 2

(4) CONTAINED I N A SEPARATE DOCUMEN T ENTITLED “REQUIRED 3
TRANSPARENCY INFORMATION FOR PATIENTS, DOCTORS, AND PURCHASERS” 4
THAT IS INCLUDED WITH ALL DOCUMENTS AND DOCUMENT PACKAGES PROVIDED TO 5
CURRENT OR PROSPECTI VE ENROLLEES , PURCHASERS, OR PARTICIPATING EYE 6
CARE PROVIDERS, AND STATE AGENCIES WITH REGULATORY AUTHORITY OVER THE 7
INSURER OR VISION BENEFIT MANAGER. 8

15–2204. 9

(A) (1) EACH INSURER OR VISION BENEFIT MANAGER SHALL MAINTAIN A 10
TELEPHONE NUMBER TO RECEIVE QUESTIONS AN D COMMUNICATIONS FRO M 11
PARTICIPATING EYE CARE PROVIDERS. 12

(2) THE TELEPHONE NUMBER REQUIRED UNDER PARAGRAPH (1) OF 13
THIS SUBSECTION SHAL L ALLOW PARTICIPATIN G EYE CARE PROVIDERS TO 14
COMMUNICATE WITH COM PANY REPRESENTATIVES DURING NORMAL BUSINE SS 15
HOURS AND TO LEAVE VOICE MESSAGES AT ALL TIMES. 16

(B) (1) EACH INSURER OR VISION BENEFIT MANAGER SHALL MAINTAIN A 17
PHYSICAL MAILING ADD RESS AND AN E –MAIL ADDRESS TO RECE IVE 18
COMMUNICATIONS FROM PARTICIPATING EYE CARE PROVIDERS. 19

(2) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL, ON THE 20
WEBSITE OF THE INSUR ER OR VIS ION BENEFIT MANAGER AND IN ANY PROVIDER 21
AGREEMENT, HANDBOOK, MANUAL, OR RELATED POLICY DOCUMENT: 22

(I) PROMINENTLY DISPLAY THE PHYSICAL MAILING ADDRESS 23
AND E–MAIL ADDRESS REQUIRED UNDER PARAGRAPH (1) OF THIS SUBSECTION; AND 24

(II) PROVIDE INSTRUCTIONS FOR THE SUBMISSION O F 25
QUESTIONS, DISPUTES, AND COMMUNICATIONS U SING THE PHYSICAL MA ILING 26
ADDRESS AND E –MAIL ADDRESS REQUIRE D UNDER PARAGRAPH (1) OF THIS 27
SUBSECTION. 28

(C) AN INSURER OR A VISION BENEFIT MANAGER SHALL: 29

(1) HAVE THE ABILITY TO HAVE A LIVE TELEPHON E DISCUSSION 30
WITHIN 24 HOURS AFTER AN INITI AL TELEPHONE CALL IS MADE TO OR A VOICE 31
MESSAGE IS LEFT WITH THE INSURER OR VISION BENEFIT MANAGER; 32

6 HOUSE BILL 1603

(2) ACKNOWLEDGE RECEIPT OF AN E–MAIL MESSAGE WITHIN 1 HOUR; 1
AND 2

(3) RESPOND TO SUBSTANTI VE QUESTIONS SUBMITT ED VIA E –MAIL 3
WITHIN 72 HOURS. 4

(D) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL, AT ALL TIMES , 5
MAKE AVAILABLE TO A PARTICIPATING EYE CA RE PROVIDER THE MOST 6
UP–TO–DATE PROVIDER AGREEM ENTS, FEE SCHEDULES , PROVIDER HANDBOOKS , 7
PROVIDER MANUALS, AND RELATED POLICY D OCUMENTS THROUGH THE WEBSITE 8
OF THE INSURER OR VISION BENEFIT MANAGER. 9

(E) ON REQUEST OF A STATE AGENCY WITH REGULATORY AUTHORITY OVER 10
THE INSURER OR VISIO N BENEFIT MANAGER , THE INSURER OR VISIO N BENEF IT 11
MANAGER SHALL SUBMIT ALL REQUESTED INFORM ATION RELATING TO TH E 12
HEALTH BENEFIT PLAN , VISION BENEFIT PLAN , OR VISION BENEFIT DI SCOUNT 13
PLAN. 14

15–2205. 15

(A) AN AGREEMENT OR CONTR ACT BETWEEN AN INSUR ER OR A VISION 16
BENEFIT MANAGER AND A PARTICIPATING EYE CARE PROVIDER: 17

(1) SHALL: 18

(I) 1. INCLUDE A FEE SCHEDU LE THAT SPECIFIES , FOR 19
EACH COVERED SERVICE AND COVERED MATERIAL , THE CORRESPONDING 20
ALLOWED AMOUNT , AMOUNT OF REIMBURSEM ENT TO BE PAID TO TH E 21
PARTICIPATING EYE CARE PROVIDER, AND ANY FORM OF COST –SHARING AMOUNT 22
TO BE PAID BY THE ENROLLEE TO THE PARTICIPATING EYE CARE PROVIDER; AND 23

2. PROVIDE THAT THE AMO UNT OF TIME FOR AN 24
INSURER OR A VISION BENEFIT MANAGER TO RECOVER A REIMBURSEMENT AMOUNT 25
FROM A PARTICIPATING EYE CARE PROVIDER SH ALL BE THE SA ME TIME PERIOD 26
ALLOWED FOR AN INSUR ER OR A VISION BENEF IT MANAGER TO REMIT 27
REIMBURSEMENT TO A P ARTICIPATING EYE CAR E PROVIDER FOLLOWING THE 28
SUBMISSION OF A CLEA N CLAIM , UNLESS THE INSURER O R VISION BENEFIT 29
MANAGER IS CONDUCTIN G AN AUDIT OF ALL OF THE PARTI CIPATING EYE CARE 30
PROVIDER’S CLAIMS BASED ON A REASONABLE BELIEF TH AT THE PARTICIPATING 31
EYE CARE PROVIDER HAS ENGAGED IN FRAUD, WASTE, OR ABUSE; AND 32

(II) INCLUDE A COPY OF TH E MOST RECENT PLAN P ROVIDER 33
MANUAL AND ANY POLIC IES REFERRED TO IN T HE PROVIDE R AGREEMENT 34
HOUSE BILL 1603 7

WHENEVER THE INSURER OR VISION BENEFIT MA NAGER SENDS A PROVID ER 1
AGREEMENT TO A PROSPECTIVE OR PARTICIPATING EYE CARE PROVIDER; AND 2

(2) MAY NOT: 3

(I) REQUIRE A PARTICIPAT ING EYE CARE PROVIDE R TO 4
PROVIDE SERVICES OR MATERIALS AT A FEE L IMITED OR SET BY THE INS URER OR 5
VISION BENEFIT MANAGER UNLESS THE SERVICES OR MATERIALS ARE DEFINED AND 6
REIMBURSED AS COVERE D SERVICES OR COVERE D MATERIALS UNDER TH E 7
AGREEMENT OR CONTRACT; 8

(II) CONTAIN A FEE SCHEDU LE, A REIMBURSEMENT AMOU NT, 9
OR ANY OTHER PROVISION THAT REQUI RES THE PARTICIPATIN G EYE CARE 10
PROVIDER TO PROVIDE COVERED SERVICES OR COVERED MATERIALS TO AN 11
ENROLLEE AT A FINANC IAL LOSS AFTER CONSI DERATION OF ALL APPL ICABLE 12
DEDUCTIBLES, COPAYS, COINSURANCES, DISCOUNTS, REBATES, OR CHARGEBACKS; 13
OR 14

(III) RESTRICT OR LIMIT , DIRECTLY OR INDIRECT LY, THE 15
PARTICIPATING EYE CA RE PROVIDER ’S CHOICE OR USE OF S OURCES AND 16
SUPPLIERS OF COVERED OR UNCOVERED SERVICE S OR MATERIALS PROVI DED BY 17
THE PARTICIPATING EYE CARE PROVIDER TO AN ENROLLEE. 18

(B) (1) AN IN SURER OR A VISION BE NEFIT MANAGER SHALL USE 19
STANDARDIZED CODES, NAMES, DESCRIPTIONS, AND DEFINITIONS PUBL ISHED IN 20
THE HEALTHCARE COMMON PROCEDURE CODING SYSTEM TO: 21

(I) IDENTIFY AND DESCRIB E COVERED SERVICES A ND 22
COVERED MATERIALS TO PURCHASERS, ENROLLEES, AND PARTICIPATING EYE CARE 23
PROVIDERS; AND 24

(II) CREATE AND OFFER A F EE SCHEDULE FOR COVE RED 25
SERVICES AND COVERED MATERIALS IN AN AGREEMENT BETWEEN THE INSURER OR 26
VISION BENEFIT MANAGER AND THE PARTICIPATING EYE CARE PROVIDER. 27

(2) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT ALTER OR 28
ATTEMPT TO ALTER THE MEANING OF ANY STAND ARDIZED CODES , NAMES, 29
DESCRIPTIONS, AND DEFINITIONS PUBL ISHED IN THE HEALTHCARE COMMON 30
PROCEDURE CODING SYSTEM. 31

(C) A FEE SCHEDULE DEVELOP ED BY AN INSURER OR A VISION BENEFI T 32
MANAGER OR REIMBURSEMENT ISSUED TO A PAR TICIPATING EYE CARE PROVIDER 33
BY AN INSURER OR A VISION BENEFIT MANAGER: 34
8 HOUSE BILL 1603

(1) SHALL PROVIDE FOR RE IMBURSEMENT FOR ALL COVERED 1
SERVICES AND COVERED MATERIALS; AND 2

(2) MAY NOT BE NOMINAL OR DE MINIMIS. 3

(D) ALL AMOUNTS ALLOWED UNDE R A FEE SCHEDULE AND 4
REIMBURSEMENTS PAID BY AN INSURER OR A VISION BENEFIT MANAGER SHALL BE 5
CLEARLY AND INDIVIDUALLY LISTED ON A FEE SCHEDULE MADE AVAILABLE TO THE 6
PARTICIPATING EYE CARE PROVIDER: 7

(1) AT THE TIME AN AGREEMENT IS OFFERED TO THE PARTICIPATING 8
EYE CARE PROVIDER BY THE INSURER OR VISION BENEFIT MANAGER; 9

(2) WITHIN 10 BUSINESS DAYS AFTER THE DATE AN APPLICAT ION IS 10
MADE TO BECOME A PAR TICIPATING EYE CARE PROVIDER WITH THE IN SURER OR 11
VISION BENEFIT MANAGER; AND 12

(3) AT ALL TIMES BY ELECTRONIC MEANS. 13

(E) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT: 14

(1) ADVERTISE, CLAIM, OR REPRESENT TO PURC HASERS OR 15
ENROLLEES THAT SERVICES AND MATERIALS PR OVIDED BY A PARTICIP ATING EYE 16
CARE PROVIDER ARE CO VERED, INCLUDED, OR COVERED WITH AN A DDITIONAL 17
DEDUCTIBLE, COPAY, OR COINSURANCE IF TH E INSURER OR VISION BENEFIT 18
MANAGER DOES NOT REMIT A N ACTUAL PAYMENT AS FULL OR PARTIAL 19
REIMBURSEMENT TO THE PARTICIPATING EYE CARE PROVIDER; 20

(2) RESTRICT A PARTICIPATING EYE CARE PROVIDER FROM: 21

(I) ENGAGING IN DIRECT NEGOTIATION WITH THE INSURER OR 22
VISION BENEFIT MANAGER REGARDING REIMBURSEMENT FEE SCHEDULES, EVEN IF 23
THE PARTICIPATING EY E CARE PROVIDER IS A N INDIVIDUAL OR A ME MBER OF A 24
GROUP OF EYE CARE PR OVIDERS PRACTICING U NDER A SINGLE EMPLOYER 25
IDENTIFICATION NUMBER OR TAX IDENTIFICATION NUMBER; OR 26

(II) AGREEING TO A DIFFERENT FEE SCHEDULE FROM THE FEE 27
SCHEDULE PROVIDED BY THE INSURER OR VISIO N BENEFIT MANAGER TO OTHER 28
PARTICIPATING EYE CARE PROVIDERS; 29

(3) DESIGNATE A SERVICE OR MATERIAL AS A COV ERED SERVICE OR 30
COVERED MATERIAL IF THE REIMBURSEMENT AMOUNT TO THE PARTICIPATING EYE 31
HOUSE BILL 1603 9

CARE PROVIDER IS COM POSED OF ONLY AN ENR OLLEE’S PAYMENT TO THE 1
PARTICIPATING EYE CARE PROVIDER; 2

(4) CONDITION APPLICATION TO OR NETWORK PART ICIPATION IN A 3
HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN 4
BY AN EYE CA RE PROVIDER BASED ON THE EYE CARE PROVIDE R’S USUAL AND 5
CUSTOMARY PRICING OR DISCOUNTS ON USUAL A ND CUSTOMARY PRICING FOR 6
SERVICES OR MATERIALS THAT ARE NOT COVERED SERVICES OR MATERIALS; 7

(5) CONDITION A PROPOSED OR EFFECTIVE FEE SCHEDULE BASED ON 8
THE E YE CARE PROVIDER ’S USUAL AND CUSTOMAR Y PRICING OR DISCOUN TS ON 9
USUAL AND CUSTOMARY PRICING FOR SERVICES OR MATERIALS THAT AR E NOT 10
COVERED SERVICES OR MATERIALS; 11

(6) REIMBURSE A PARTICIPATING EYE CARE PROVIDER A DIFFERENT 12
AMOUNT FOR COVERED S ERVICES OR COVERED MATERIALS BE CAUSE OF THE 13
PARTICIPATING EYE CARE PROVIDER’S CHOICE OF: 14

(I) OPTICAL LABORATORY; 15

(II) SOURCE OF SUPPLIER FOR CONTACT LENSES, OPHTHALMIC 16
LENSES, OPHTHALMIC GLASSES FRAMES, OR OTHER SERVICES OR MATERIALS; 17

(III) EQUIPMENT USED FOR PATIENT CARE; 18

(IV) RETAIL OPTICAL AFFILIATION; 19

(V) VISION SUPPORT ORGANIZATION; 20

(VI) GROUP PURCHASING ORGANIZATION; 21

(VII) DOCTOR ALLIANCE; 22

(VIII) PROFESSIONAL TRADE ASSOCIATION MEMBERSHIP; 23

(IX) ELECTRONIC HEALTH RE CORD SOFTWARE, ELECTRONIC 24
MEDICAL RECORD SOFTWARE, OR PRACTICE MANAGEMENT SOFTWARE; OR 25

(X) THIRD–PARTY CLAIM FILING S ERVICE, BILLING SERVICE , 26
OR ELECTRONIC DATA INTERCHANGE CLEARINGHOUSE COMPANY; 27

(7) REQUIRE A PARTICIPATING EYE CARE PROVIDER, A PURCHASER, 28
OR AN ENROLLEE OF A HEALTH PLAN, VISION BENEFIT PLAN , OR VISION BENEFIT 29
10 HOUSE BILL 1603

DISCOUNT PLAN TO OBT AIN PRIOR AUTHORIZAT ION, PREAUTHORIZATION, 1
PRECERTIFICATION, OR ANY SIMILAR MECHANISM THAT RESTRICTS THE ENROLLEE 2
FROM RECEIVING A COVERED SERVICE OR COVERED MATERIAL RECOMMENDED BY 3
THE PARTICIPATING EYE CARE PROVIDER AND REQUESTED BY THE ENROLLEE; OR 4

(8) IN THE COURSE OF ADJ UDICATING A CLAIM FO R 5
REIMBURSEMENT, ALTER, DELETE, SUBSTITUTE, OR OTHERWISE CHANGE ANY CODE 6
OR MODIFIER SUBMITTED BY THE PARTICIPATING EYE CARE PROVIDER, INCLUDING 7
BY DOWNCODING , BUNDLING, OR REASSIGNING TO A DIFFERENT CODE , IF THE 8
CHANGE WOULD REDUCE PAYMENT OR OTHERWISE ADVERSELY AFFECT THE 9
PARTICIPATING EYE CARE PROVIDER OR ENROLLEE. 10

(F) (1) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL REMIT TO 11
THE PARTICIPATING EY E CARE PROVIDER THE CONTRACTED REIMBURSE MENT 12
AMOUNT FROM THE FEE SCHEDULE FOR A COVER ED SERVICE OR COVERE D 13
MATERIAL PROVIDED TO AN ENROLLEE IF THE E NROLLEE IS VERIFIED TO BE 14
ELIGIBLE BY THE PART ICIPATING EYE CARE P ROVIDER THROU GH CUSTOMARY 15
VERIFICATION METHODS OF THE INSURER OR VI SION BENEFIT MANAGER TO 16
RECEIVE THE COVERED SERVICE OR COVERED MATERIAL ON THE DATE OF SERVICE. 17

(2) AN INSURER OR A VISIO N BENEFIT MANAGER MA Y NOT 18
RETROACTIVELY REVERS E A REIMBURSEMENT OR WITHHOLD A FUTURE 19
REIMBURSEMENT TO A PARTICIPATING EYE CARE PROVIDER WHO RELIED IN GOOD 20
FAITH ON AN INDIVIDU AL’S PRESENTED COVERAGE CREDENTIALS AND THE 21
CUSTOMARY VERIFICATI ON METHODS OF THE IN SURER OR VISION BENE FIT 22
MANAGER IF THE INSURER OR VISION BENEFIT MANAGER LATER DETERMINES THAT 23
THE ENROLLEE WAS INELIGIBLE TO RECEIVE THE COVERED SERVICES OR COVERED 24
MATERIALS ON THE DATE OF SERVICE. 25

(G) (1) A PARTICIPATING EYE CARE PROVIDER MAY OFFER AN ENROLLEE 26
THE OPPORTUNITY TO PAY THE PARTICIPATING EYE CARE PROVIDER DIRECTLY FOR 27
COVERED SERVICES OR COVERED MATERIALS IF THE DIRECT PAYMENT WOULD BE 28
LESS COSTLY TO THE E NROLLEE THAN THE TOT AL OUT –OF–POCKET COST 29
REQUIRED UNDER THE TERMS OF THE HEALTH B ENEFIT PLAN OR VISION BENEFIT 30
PLAN. 31

(2) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT SUBJECT A 32
PARTICIPATING EYE CA RE PROVIDER TO AN AU DIT, REMOVE THE PARTICIPA TING 33
EYE CARE PROVIDER FR OM PARTICIPATION IN THE NETWORK , OR OTHERWISE 34
PENALIZE OR DISCRIMINATE AGAINST A PARTI CIPATING EYE CARE PROVIDER FOR 35
OFFERING AN ENROLLEE THE OPPORTUNITY TO PAY THE PARTICIPATING EYE CARE 36
PROVIDER DIRECTLY UNDER PARAGRAPH (1) OF THIS SUBSECTION. 37

HOUSE BILL 1603 11

(H) AN AGREEMENT BETWEEN AN INSURER OR A VISION BENEFIT MANAGER 1
AND A PARTICIPATING EYE CARE PROVIDER MAY NOT REQUIRE THE PARTICIPATING 2
EYE CARE PROVIDER TO ACCEPT A RE IMBURSEMENT PAYMENT IN THE FORM OF A 3
VIRTUAL CREDIT CARD OR A FORM OF PAYMENT IN WHICH A PROCESSIN G FEE , 4
ADMINISTRATIVE FEE, PERCENTAGE AMOUNT, OR DOLLAR AMOUNT IS ASSESSED TO 5
THE PROVIDER TO RECEIVE THE REIMBURSEMENT PAYMENT. 6

15–2206. 7

(A) THIS SECTION APPLIES TO AN AGREEMENT AN I NSURER OR A VISION 8
BENEFIT MANAGER ENTERS INTO WITH ANOTHER ENTITY TO PROVIDE AN ENROLLEE 9
WITH COVERED SERVICES OR COVERED MATERIALS. 10

(B) AN AGREEMENT BETWEEN AN INSURER OR A VISION BENEFIT PLAN AND 11
A PARTICIPATING EYE CARE PROVIDER MAY NOT REQUIRE THE PARTICIPATING EYE 12
CARE PROVIDER TO PAR TICIPATE IN , BE CREDENTIALED BY , OR ENTER INTO AN 13
AGREEMENT WITH: 14

(1) A SPECIFIC VISION BENEFIT PLAN OR VISION BENEFIT DISCOUNT 15
PLAN AS A CONDITION OF PARTICIPATION IN THE HEALTH BENEFIT PLAN PROVIDER 16
NETWORK OF THE INSURER OR VISION BENEFIT MANAGER; OR 17

(2) A SPECIFIC HEALTH BE NEFIT PLAN AS A COND ITION OF 18
PARTICIPATION IN THE VISION BENEFIT PLAN OR VISION BENEFIT DISCOUNT PLAN 19
PROVIDER NETWORK OF THE INSURER OR VISION BENEFIT MANAGER. 20

(C) AN INSURER OR A VISION BENEFIT MANAGER ISSUING OR RENEWING A 21
HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN 22
THAT PROVIDES BENEFI TS FOR COVERED SERVI CES OR COVERED MATER IALS 23
PROVIDED BY A PHYSIC IAN OR THAT ARE WITHIN THE SCOPE OF PRACTICE OF AN 24
OPTOMETRIST LICENSED UNDER TITLE 11 OF THE HEALTH OCCUPATIONS ARTICLE 25
SHALL PROVIDE THE SA ME REIMBURSEMENT FOR COVERED SERVICES AND 26
COVERED MATERIALS TO OPTOMETRISTS AT THE SAME RATE AS THE COV ERED 27
SERVICES AND COVERED MATERIALS WHEN PROVIDED BY A PHYSICIAN. 28

(D) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL APPLY THE SAME 29
TERMS AND CONDITIONS OF PARTICIPATION FOR ALL PARTICIPATING EY E CARE 30
PROVIDERS IRRESPECTI VE OF THE PARTICIPAT ING EYE CARE PROVIDE R’S 31
EDUCATIONAL CREDENTIALS. 32

(E) AN INSURER OR A VISIO N BENEFIT MANAGER MA Y NOT REQUIRE A 33
PARTICIPATING EYE CARE PROVIDER TO POSSESS, OFFER, OR SELL MATERIALS OR 34
COVERED MATERIALS IN ITS OFFICE AS A COND ITION OF PARTICIPATI ON IN THE 35
12 HOUSE BILL 1603

PROVIDER NETWORK OF THE HEALTH B ENEFIT PLAN , VISION BENEFIT PLAN , OR 1
VISION BENEFIT DISCOUNT PLAN. 2

(F) (1) THIS SUBSECTION APPLIES TO ALL PLANS SOLD, ADMINISTERED, 3
OR OFFERED BY A HEAL TH BENEFIT PLAN , VISION BENEFIT PLAN , OR VISION 4
BENEFIT DISCOUNT PLAN. 5

(2) AN INSURER OR A VISIO N BENEFIT MANAGER MAY NOT REQUIRE 6
A PARTICIPATING EYE CARE PROVIDER TO PARTICIPATE IN THE NETWORK OF ANY 7
OF THE INSURER’S OR VISION BENEFIT MANAGER’S OTHER HEALTH BENEFIT PLANS, 8
VISION BENEFIT PLANS, OR VISION BENEFIT DISCOUNT PLANS, AS A CONDITION OF 9
PARTICIPATION IN A NETWORK OF THE INSURER, VISION BENEFIT PLAN, OR VISION 10
BENEFIT DISCOUNT PLAN. 11

(3) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT WITHHOLD 12
PARTICIPATION IN THE NETWORK OF ONE OR MO RE OF THE INSURER ’S OR VISION 13
BENEFIT MANAGER’S OTHER HEALTH BENEFIT PLANS, VISION BENEFIT PLANS, OR 14
VISION BENEFIT DISCO UNT PLANS FROM A PAR TICIPATING EYE CARE PROVIDER 15
WHO: 16

(I) HAS COMPLETED THE CR EDENTIALING REQUIREMENTS OF 17
THE INSURER OR VISION BENEFIT MANAGER; AND 18

(II) IS ALREADY PARTICIPA TING IN ONE O R MORE OF THE 19
INSURER’S OR VISION BENEFIT MANAGER’S HEALTH BENEFIT PLA NS, VISION 20
BENEFIT PLANS, OR VISION BENEFIT DISCOUNT PLANS. 21

15–2207. 22

(A) AN INSURER ’S OR A VISION BENEFI T MANAGER ’S APPLICATION FOR 23
INCLUSION AND CREDEN TIALING AS A PARTICI PATING EYE CARE PROVIDER IN A 24
HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN 25
MAY REQUIRE ONLY: 26

(1) THE STANDARDIZED INF ORMATION SPECIFIED I N § 15–112.1 OF 27
THIS TITLE; OR 28

(2) INFORMATION SPECIFIE D IN THE COUNCIL FOR AFFORDABLE 29
QUALITY HEALTHCARE CREDENTIALING APPLICATION. 30

(B) AN INSURER OR A VISION BENEFIT MANAGER SHALL IMPOSE THE SAME 31
APPLICATION AND CRED ENTIALING REQUIREMENTS ON ALL PARTICIPAT ING EYE 32
CARE PROVIDERS IN THE HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION 33
HOUSE BILL 1603 13

BENEFIT DISCOUNT PLAN. 1

(C) AN INSURER OR A VISIO N BENEFIT PLAN SHALL PROVIDE A PROPOSED 2
PARTICIPATING PROVIDER AGREEMENT, INCLUDING APPLICABLE FEE SCHEDULES, 3
PROVIDER HANDBOOKS , AND PROVIDER MANUALS , TO AN EYE CARE PROVI DER 4
WITHIN 10 BUSINESS DAYS AFTER RECEIVING THE EYE CA RE PROVID ER’S 5
APPLICATION FOR INCLUSION AND CREDENTIALING AS A PARTICIPATING PROVIDER 6
IN THE HEALTH BENEFI T PLAN , VISION BENEFIT PLAN , OR VISION BENEFIT 7
DISCOUNT PLAN. 8

(D) (1) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL COMPLETE 9
THE CREDENTIALING DE TERMINATION OF THE APPLICANT EYE CARE PROVIDER 10
AND NOTIFY THE APPLICANT EYE CARE PROVIDER OF THE APPROVAL OR DENIAL OF 11
AN EYE CARE PROVIDER’S APPLICATION FOR INCLUSION AND CREDENTIALING AS A 12
PARTICIPATING PROVIDER IN THE HEALTH BEN EFIT PLAN, VISION BENEFIT PLAN, 13
OR VISION BENEFIT DISCOUNT PLAN WITHIN 30 BUSINESS DAYS AFTER RECEIVING 14
THE APPLICATION. 15

(2) A NOTIFICATION OF AN APPROVAL PROVIDED UNDER PARAGRAPH 16
(1) OF THIS SUBSECTION SHALL INCLUDE: 17

(I) A PROPOSED PROVIDER AGREEMENT FOR ACCEPT ANCE 18
AND SIGNATURE OF THE EYE CARE PROVIDER; AND 19

(II) THE NAME, TELEPHONE NUMBER, AND E–MAIL ADDRESS OF 20
A REPRESENTATIVE OF THE INSURER OR VISIO N BENEFIT MANAGER TO PROVIDE 21
THE EYE CARE PROVIDER WITH THE OPPORTUNITY TO: 22

1. CONTACT THE REPRESEN TATIVE TO DISCUSS TH E 23
PROPOSED AGREEMENT BEFORE SIGNING; AND 24

2. ELECTRONICALLY SEND PROPOSED MODIFICATIONS 25
TO THE PROPOSED AGREEMENT TO THE REPRESENTATIVE. 26

(3) AN INSURER OR A VISION BENEFIT MANAGER SHALL RESPOND TO 27
A PROPOSED MODIFICAT ION SUBMITTED UNDER PARAGRAPH (2)(II)2 OF THIS 28
SUBSECTION WITHIN 5 BUSINESS DAYS AFTER RECEIPT. 29

(4) (I) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL 30
PROVIDE AN APPROVED EYE CARE PROVIDER 90 BUSINESS DAYS TO EXE CUTE THE 31
PARTICIPATING PROVIDER AGREEMENT DELIVER ED UNDER PARAGRAPH (2)(I) OF 32
THIS SUBSECTION. 33

14 HOUSE BILL 1603

(II) IF AN APPROVED EYE CARE PROVIDER HAS NOT EXECUTED 1
THE PARTICIPATING PROVIDER AGREEMENT DELIVERED UNDER PARAGRAPH (2)(I) 2
OF THIS SUBSECTION WITHIN 90 BUSINESS DAYS AFTER RECEIPT, THE INSURER OR 3
VISION BENEFIT MANAG ER MAY RETRACT THE P ARTICIPATING PROVIDE R 4
AGREEMENT. 5

(E) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL ALLOW AN EYE 6
CARE PROVIDER TO BECOME A PARTICIPATING EYE CARE PROVIDER IN THE HEALTH 7
BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN IF: 8

(1) THE EYE CARE PROVIDER MEETS THE CREDENTIALING 9
REQUIREMENTS OF THE INSURER OR VISION BENEFIT MANAGER; AND 10

(2) THE EYE CARE PROVIDE R SIGNS THE APPLICAB LE PROVIDER 11
AGREEMENT. 12

(F) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT EXCLUDE AN EYE 13
CARE PROVIDER FROM A PPLYING TO BECOME OR FROM BECOMING A 14
PARTICIPATING PROVIDER IN THE NETWORK OF A HEALTH BENEFIT PLA N, VISION 15
BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN BASED ON: 16

(1) THE AGGREGATE NUMBER OF EYE CARE PROVIDER S IN THE 17
STATE, OR A COUNTY , CITY, ZIP CODE , OR OTHER GEOGRAPHICA LLY DEFINED 18
SERVICE AREA; 19

(2) THE TIME , DISTANCE, OR APPOINTMENT AVAIL ABILITY FOR AN 20
ENROLLEE TO ACCESS A PARTICIPATING EYE CARE PROVIDER; OR 21

(3) THE EYE CARE PROVIDE R’S PROFESSIONAL DESIG NATION, 22
INDEPENDENT PRACTICE AFFILIATION, OR PARTICIPATION IN OTHER HEALTH 23
BENEFIT PLANS, VISION BENEFIT PLANS, OR VISION BENEFIT DISCOUNT PLANS. 24

(G) WITHIN 20 DAYS AFTER THE EXECU TION OF A PARTICIPAT ING 25
PROVIDER AGREEMENT, AN INSURER OR A VISION BENEFIT MANAGER SHALL: 26

(1) INCLUDE THE PART ICIPATING EYE CARE P ROVIDER AS A 27
PARTICIPATING PROVIDER IN THE HEALTH BEN EFIT PLAN, VISION BENEFIT PLAN, 28
OR VISION BENEFIT DISCOUNT PLAN; AND 29

(2) LIST THE PARTICIPATI NG EYE CARE PROVIDER IN ALL PLAN 30
DIRECTORIES AVAILABLE TO ENROLLEES AND THE PUBLIC. 31

(H) (1) IF AN INSURER OR A VI SION BENEFIT MANAGER DENIES AN EYE 32
HOUSE BILL 1603 15

CARE PROVIDER ’S APPLICATION FOR IN CLUSION AND CREDENTI ALING AS A 1
PARTICIPATING PROVIDER IN A HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR 2
VISION BENEFIT DISCO UNT PLAN , THE INSURER OR VISIO N BE NEFIT MANAGER 3
SHALL DELIVER A DETA ILED EXPLANATION FOR THE DENIAL TO THE AP PLICANT 4
EYE CARE PROVIDER ELECTRONICALLY AND IN WRITING BY CERTIFIED MAIL. 5

(2) (I) AN INSURER OR A VISION BENEFIT MANAGER SHALL ALLOW 6
AN EYE CARE PROVIDER TO APPEAL A DENIAL OF AN APPLICATION FOR INCLUSION 7
AND CREDENTIALING AS A PARTICIPATING PROV IDER WITHIN A REASON ABLE 8
PERIOD OF TIME. 9

(II) AN INSURER OR A VISIO N BENEFIT MANAGER SH ALL 10
RENDER A DECISION ON AN APPEAL FILED UNDE R SUBPARAGRAPH (I) OF THIS 11
PARAGRAPH WITHIN 30 DAYS AFTER THE INSURER’S OR VISION BENEFIT MANAGER’S 12
RECEIPT OF THE REQUEST FOR THE APPEAL. 13

(3) IF AN APPEAL FILED UNDER PARAGRAPH (2) OF THIS SUBSECTION 14
IS DENIED BY THE INSURER OR VISION BENEFIT MANAGER: 15

(I) THE INSURER OR VISIO N BENEFIT MANAGER SHALL 16
DELIVER A DETAILED EXPLANATION FOR THE DENIAL TO THE APPLICANT EYE CARE 17
PROVIDER ELECTRONICALLY AND IN WRITING BY CERTIFIED MAIL; AND 18

(II) THE EYE CARE PROVIDE R MAY APPEAL THE DEC ISION TO 19
THE ADMINISTRATION. 20

(I) AN EYE CARE PROVIDER MAY NOT SUBMIT ANOTHER APPLICATION FOR 21
INCLUSION AND CREDENTIALING AS A PARTICIPATING PROVIDER WITHIN 180 DAYS 22
AFTER THE EYE CARE PROVIDER’S MOST RECENT APPLICATION FOR INCLUSION AND 23
CREDENTIALING AS A P ARTICIPATING PROVIDER IN THE SAME HEALTH BENEFIT 24
PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN WAS: 25

(1) DENIED; OR 26

(2) APPROVED BUT A PARTI CIPATING PROVIDER AG REEMENT WAS 27
NOT EXECUTED. 28

(J) AN INSURER OR A VISION BENEFIT MANAGER: 29

(1) SHALL MAINTAIN A PRO VIDER AGREEMENT AS A DISTINCT AND 30
SEPARATE DOCUMENT FROM ANY CREDENTIALING MATERIALS; AND 31

(2) MAY NOT CONSTRUE REC REDENTIALING AS RECO NTRACTING 32
16 HOUSE BILL 1603

WITH A PARTICIPATING EYE CARE PROVIDER. 1

15–2208. 2

(A) (1) AT LEAST 90 DAYS BEFORE THE EFFE CTIVE DATE OF AN 3
ALTERATION TO A PROVIDER AGREEMENT OR A PROVIDER MANUAL INCORPORATED 4
BY REFERENCE INTO A PROVIDER AGREEMENT, AN INSURER OR A VISI ON BENEFIT 5
MANAGER SHALL: 6

(I) PROVIDE NOTICE TO TH E PARTICIPATING EYE CARE 7
PROVIDER OF THE PROPOSED CHANGE; AND 8

(II) IF REQUESTED BY THE PARTICIPATING EYE C ARE 9
PROVIDER, DISCUSS THE PROPOSED CHANGES IN A FACE –TO–FACE OR VIRTUAL 10
MEETING WITH THE PARTICIPATING EYE CARE PROVIDER. 11

(2) THE NOTICE REQUIRED U NDER PARAGRAPH (1) OF THIS 12
SUBSECTION SHALL: 13

(I) CONTAIN A COVER LETT ER ENUMERATING THE P ROPOSED 14
CHANGES; 15

(II) CONTAIN A COPY OF TH E AMENDED DOCUMENT W ITH THE 16
CHANGES CLEARLY MARKED; AND 17

(III) BE STRUCTURED TO INC LUDE IMPLICATIONS OF THE 18
AGREEMENT OR NONAGRE EMENT TO THE PROPOSE D CHANGES BY THE 19
PARTICIPATING EYE CARE PROVIDER. 20

(3) IF A PART ICIPATING EYE CARE P ROVIDER DOES NOT PRO VIDE 21
WRITTEN APPROVAL OF PROPOSED CHANGES PROVIDED UNDER PARAGRAPH (1) OF 22
THIS SUBSECTION WITHIN 90 DAYS AFTER THE PROPOSED EFFECTIVE DATE: 23

(I) THE EXISTING PROVIDE R AGREEMENT SHALL RE MAIN IN 24
FORCE BETWEEN THE PARTIES; AND 25

(II) THE INSURER OR VISIO N BENEFIT MANAGER MA Y NOT 26
REMOVE THE PARTICIPA TING EYE CARE PROVID ER FROM PARTICIPATIO N IN THE 27
HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN 28
BASED ON THE PARTICI PATING EYE CARE PROV IDER’S FAILURE TO APPROVE T HE 29
PROPOSED CHANGES. 30

(B) A PROVIDER AGREEMENT M AY NOT BE TERMINATED BY THE INSURER 31
HOUSE BILL 1603 17

OR VISION BENEFIT MANAGER UNLESS: 1

(1) THE PARTICIPATING EY E CARE PROVIDER HAS COMMITTED A 2
MATERIAL BREACH; 3

(2) THE INSURER OR VISIO N BENEFIT MANAGER PROVIDES THE 4
PARTICIPATING EYE CA RE PROVIDER WITH WRI TTEN NOTICE SPECIFYI NG THE 5
ALLEGED BREACH; AND 6

(3) THE PARTICIPATING EYE CARE PROVIDER FAILS TO REMEDY THE 7
ALLEGED BREACH TO THE REASONABLE SATISFACTION OF THE INSURER OR VISION 8
BENEFIT MANAGE R WITHIN 30 DAYS AFTER NOTIFICAT ION OF THE ALLEGED 9
BREACH. 10

(C) AN INSURER OR A VISIO N BENEFIT MANAGER MA Y NOT REQUIRE A 11
PARTICIPATING EYE CARE PROVIDER TO ESTABLISH A SECURITY INTEREST IN ALL 12
OR PART OF ITS PROPERTY AND ASSETS IN A SUM EQUIVALENT TO FUNDS OWED TO 13
THE INSURER OR VISION BENEFIT MANAGER AT TERMINATION. 14

(D) A PROVIDER AGREEMENT BETWEEN AN INSURER OR A VISION BENEFIT 15
MANAGER AND A PARTICIPATING EYE CARE PROVIDER SHALL SPECIFY THAT EACH 16
PARTY SHALL BE RESPONSIBLE FOR ITS OWN ARBITRATION COSTS, CONTINGENT ON 17
A FEE–SHIFTING PROVISION THAT GRANTS PREVAILING PARTY STATUS. 18

(E) (1) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT RETALIATE 19
AGAINST AN EYE CARE PROVIDER FOR: 20

(I) DISCUSSING, OR ATTEMPTING IN GOO D FAITH TO 21
NEGOTIATE, THE TERMS OF A PROVIDER AGREEMENT WITH THE INSURER OR VISION 22
BENEFIT MANAGER; OR 23

(II) FILING A COMPLAINT A GAINST THE INSURER O R VISION 24
BENEFIT MANAGER WITH ANY STATE AGENCY WITH REGULATORY AUTHORITY OVER 25
THE INSURER OR VISION BENEFIT MANAGER. 26

(2) THE COMMISSIONER MAY IMPO SE PENALTIES AGAINST AN 27
INSURER OR A VISION BENEFIT MANAGER FOR A VIOLATION OF THIS SUBSECTION. 28

15–2209. 29

(A) AN INSURER OR A VISION BENEFIT MANAGER MAY NOT: 30

(1) CONTROL OR ATTEMPT TO CONTROL T HE PROFESSIONAL 31
18 HOUSE BILL 1603

JUDGMENT, MANNER OF PRACTICE , OR PRACTICE OF A PAR TICIPATING EYE CARE 1
PROVIDER; 2

(2) EMPLOY A PARTICIPATI NG EYE CARE PROVIDER TO PROVIDE A 3
COVERED SERVICE OR COVERED MATERIAL; 4

(3) RESTRICT, LIMIT, OR INFLUENCE A P ARTICIPATING EYE CAR E 5
PROVIDER’S CHOICE OF ELECTRON IC HEALTH RECORD SOF TWARE, ELECTRONIC 6
MEDICAL RECORD SOFTW ARE, PRACTICE MANAGEMENT SOFTWARE, OR 7
THIRD–PARTY CLAIM FILING S ERVICE, BILLING SERVICE , OR ELECTRONIC DATA 8
INTERCHANGE CLEARINGHOUSE COMPANY; 9

(4) RESTRICT, LIMIT, OR INFLUENCE A PARTI CIPATING EYE CARE 10
PROVIDER’S CHOICE OF SOURCES OR SUPPLIERS OF SERV ICES OR MATERIALS , 11
INCLUDING OPTICAL LA BORATORIES, USED BY THE PARTICIP ATING EYE CARE 12
PROVIDER TO PROVIDE SERVICES OR MATERIALS TO THE ENROLLEE; 13

(5) RESTRICT OR LIMIT A PARTICIPATING EYE CA RE PROVIDER ’S 14
ACCESS TO AN ENROLLEE’S COMPLETE PLAN COVERAGE INFORMATION, INCLUDING 15
IN–NETWORK AND OUT–OF–NETWORK COVERAGE DETAILS; 16

(6) APPLY A CHARGEBACK TO AN ENROLLEE OR EYE CARE PROVIDER 17
FOR A COVERED PRO DUCT OR SERVICE FOR WHICH THE INSURER OR VISION 18
BENEFIT MANAGER DOES NOT INCUR THE COST TO PRODUCE, DELIVER, OR PROVIDE 19
TO THE ENROLLEE OR PARTICIPATING EYE CARE PROVIDER; 20

(7) SOLICIT PATIENTS OR REFERRALS FOR SUPPLIES ON BEHALF OF 21
THE INSURER OR VISIO N BENEFIT PLAN OR ITS AFFILIATES BY IDENTI FYING 22
PARTICIPATING EYE CARE PROVIDERS IN AN INACCURATE OR MISLEADING MANNER 23
IN ANY LIST OF PARTI CIPATING PROVIDERS O R ANY COMMUNICATIONS TO 24
PURCHASERS OR ENROLLEES; 25

(8) FALSELY REPRESENT THE NUMBER OF PARTICIPATING EYE CARE 26
PROVIDERS IN A REGION; 27

(9) FALSELY REPRESENT THE BENEFITS THAT CONSTITUTE A HEALTH 28
BENEFIT PLAN , VISION BENEFIT PLAN , OR VISION BENEFIT DI SCOUNT PLAN TO 29
CLIENTS, GROUPS, PURCHASERS, COMPANIES, ENROLLEES, OR PROSPECTIVE 30
ENROLLEES; 31

(10) STATE IN ANY MARKETI NG OR ADVERTISING FO R A HEALTH 32
BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN THAT A 33
COVERED SERVICE OR C OVERED MATERIAL IS “FREE”, “NO CHARGE ”, 34
HOUSE BILL 1603 19

“COMPLIMENTARY”, OR ANY SIMILAR LANGUAGE TO INDUCE A CLIENT, A GROUP, AN 1
EMPLOYER, A PURCHASER , A COMPANY , AN ENROLLEE , OR A PROSPECTIVE 2
ENROLLEE TO PURCHASE SERVICES FROM THE IN SURER, VISION BENEFIT 3
MANAGER, OR AFFILIATE OF THE INSURER OR VISION BENEFIT MANAGER; 4

(11) OFFER ENROLLEES OF A HEALTH BENEFIT PLAN, VISION BENEFIT 5
PLAN, OR VISION BENEFIT DI SCOUNT PLAN VARYING DEDUCTIBLES, COPAYS, 6
COINSURANCE, COVERAGE AMOUNTS , REBATES, GIFT CARDS , OR OTHER 7
INCENTIVES TO OBTAIN SERVICES OR MATERIALS FROM: 8

(I) A PARTICULAR EYE CARE PROVIDER; OR 9

(II) A RETAIL ESTABLISHME NT O R INTERNET OR VIRTUAL 10
PROVIDER OR RETAILER OWNED BY, PARTIALLY OWNED BY, CONTRACTED WITH, OR 11
OTHERWISE AFFILIATED WITH THE INSURER OR VISION BENEFIT MANAGER; OR 12

(12) REQUIRE AN EYE CARE PROVIDER TO DISCLOSE OR REPORT: 13

(I) AN ENROLLEE ’S CONFIDENTIAL OR PROTECTED HEALTH 14
INFORMATION UNLESS T HE DISCLOSURE IS EXP RESSLY AUTHORIZED BY THE 15
ENROLLEE OR PERMITTE D WITHOUT AUTHORIZAT ION UNDER THE HEALTH 16
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996; 17

(II) AN ENROLLEE ’S MEDICAL HISTORY OR DIAGNOSIS AS A 18
CONDITION TO FILE A CLAIM, ADJUDICATE A CLAIM, OR RECEIVE REIMBURSEMENT 19
FOR A ROUTINE OR WELLNESS EYE EXAM; OR 20

(III) UNLESS THE INFORMATION IS NEEDED BY THE INSURER OR 21
VISION BENEFIT MANAGER TO AID IN THE MANUFACTURE OF A COVERED PRODUCT 22
OR COVERED MATERIAL SUBMITTED ON THE APPLICABLE CLAIM: 23

1. AN ENROLLEE ’S GLASSES OR CONTACT LENS 24
PRESCRIPTION, OPHTHALMIC DEVICE MEASUREMENT, OR FACIAL PHOTOGRAPH; OR 25

2. ANY ENROLLEE INFORMA TION OTHER THAN 26
INFORMATION IDENTIFIED IN THE CURRENT APPLICABLE VERSION OF THE HEALTH 27
INSURANCE CLAIM FORM APPROVED BY THE NATIONAL UNIFORM CLAIM 28
COMMITTEE AS A CONDITION TO ADJUDICATE A CLAIM, FILE A CLAIM, OR RECEIVE 29
REIMBURSEMENT. 30

(B) A COMMUNICATION FROM AN INSURER OR A VISION BENEFIT MANAGER 31
THAT DISTINGUISHES BETWEEN EYE CARE PROVIDERS OR THAT OTHERWISE CLAIMS 32
PROFESSIONAL SUPERIORITY OR THE PERFORMANCE OF A SERVICE IN A SUPERIOR 33
20 HOUSE BILL 1603

MANNER SHALL BE SUBJ ECT TO VERIFICATION BY THE ADMINISTRATION IF THE 1
COMMUNICATION REFERENCES: 2

(1) A DISCOUNT OR AN INCENTIVE OFFERED BY A PARTICIPATING EYE 3
CARE PROVIDER ON NONCOVERED SERVICES OR NONCOVERED MATERIALS; 4

(2) THE DOLLAR AMOUNT, VOLUME AMOUNT, OR PERCENTAGE USAGE 5
AMOUNT OF ANY MATERIAL, PRODUCT, OR GOOD PURCHASED BY A PARTICIPATING 6
EYE CARE PROVIDER; OR 7

(3) THE BRAND , SOURCE, MANUFACTURER, OR SUPPLIER OF A 8
COVERED SERVICE OR C OVERED MATERIAL UTIL IZED BY A PARTICIPAT ING EYE 9
CARE PROVIDER. 10

(C) THIS SECTION MAY NOT BE CONSTRUED TO LIMI T OR PROHIBIT 11
ADVERTISEMENTS THAT DO NOT OTHERWISE VIOLATE THIS SUBTITLE OR TITLE 13 12
OF THE COMMERCIAL LAW ARTICLE. 13

15–2210. 14

(A) AN INSURER OR A VISIO N BENEFIT MANAGER MA Y NOT USE 15
EXTRAPOLATION TO COM PLETE AN AUDIT OF A PARTICIPATING EYE CA RE 16
PROVIDER. 17

(B) ANY ADDITIONAL PAYMEN T DUE TO A PARTICIPA TING EYE CARE 18
PROVIDER OR ANY REFUND DUE TO AN INSURER OR A VISION BENEFIT MANAGER 19
SHALL BE BASED ON TH E ACTUAL OVERPAYMENT OR UNDERPAYMENT AS 20
DETERMINED AFTER AN INVESTIGATION BY THE INSURER OR VISION BE NEFIT 21
MANAGER. 22

(C) AN INVESTIGATION COND UCTED UNDER SUBSECTI ON (B) OF THIS 23
SECTION MAY NOT CONCLUDE UNTIL THE PARTICIPATING EYE CARE PROVIDER WHO 24
IS SUBJECT TO THE IN VESTIGATION HAS EXHA USTED ALL OPPORTUNIT IES TO 25
APPEAL THE INSURER ’S OR VISION BENEFIT MANAGER’S FINDINGS UNDER THE 26
PROVIDER MANUAL OR POLICY DOCUMENT AND ANY APPLICABLE LAWS. 27

15–2211. 28

(A) SUBJECT TO SUBSECTION (B) OF THIS SECTION, AN EYE CARE PROVIDER 29
ADVERSELY AFFECTED BY A VIOLATION OF THI S SUBTITLE MAY BRING AN ACTION 30
FOR INJUNCTIVE RELIE F AND TO RECOVER MON ETARY DAMAGES INCLUD ING 31
DIRECT, INDIRECT, COMPENSATORY, AND PUNITIVE DAMAGES PLUS ATTORNEY ’S 32
FEES AND COSTS. 33
HOUSE BILL 1603 21

(B) DAMAGES AWARDED IN AN ACTION BROUGHT UNDER SUBSECTION (A) 1
OF THIS SECTION MAY NOT EXCEED $10,000 PER VIOLATION. 2

15–2212. 3

(A) AN INSURER OR A VISIO N BENEFIT MANAGER MA Y NOT REQUIRE A 4
PARTICIPATING EYE CARE PROVIDER TO OPT INTO OR OPT OUT OF THE PROVISIONS 5
OF THIS SUBTITLE. 6

(B) ANY SUBCONTRACT AGREEMENT BETWEEN A PARTICIPATING EYE CARE 7
PROVIDER AND ANOTHER PROVIDER TO PROVIDE LICENSED HEALTH CARE 8
SERVICES TO AN ENROL LEE OR COVERED DEPEN DENT OF AN ENROLLEE OF A 9
HEALTH BENEFIT PLAN, VISION BENEFIT PLAN, OR VISION BENEFIT DISCOUNT PLAN 10
IN WHICH THE SUBCONTRACTED PROVIDER WILL SEEK REIMBURSEMENT FROM THE 11
PLAN OR THE ENROLLEE FOR THE SUBCONTRACTED SERVICES SHALL MEET THE 12
REQUIREMENTS OF THIS SUBTITLE. 13

(C) ANY CONTRACTUAL LANGUAGE THAT VIOLATES TH IS SUBTITLE SHALL 14
BE VOID AND UNENFORCEABLE AS A MATTER OF LAW. 15

15–2213. 16

THE COMMISSIONER SHALL ADOPT REGULATIONS TO: 17

(1) PROVIDE A MECHANISM FOR AGGRIEVED INDIVIDUALS TO SUBMIT 18
COMPLAINTS TO THE COMMISSIONER FOR REVI EW, INVESTIGATION, AND 19
DISCIPLINE, AS APPROPRIATE; AND 20

(2) ENSURE THAT INSURERS AND VISION BENEFIT M ANAGERS 21
COMPLY WITH THE REQUIREMENTS OF THIS SUBTITLE. 22

SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 23
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 24
after January 1, 2027. 25

SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 26
January 1, 2027. 27