Fairness in vision care; establish requirements for contracts between insurers and vision benefit providers and eye care providers.

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To: Insurance
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Zuber

HOUSE BILL NO. 1328

AN ACT ESTABLISHING REQUIREMENTS RELATING TO CONTRACTS AND 1
AGREEMENTS BETWEEN INSURERS AND VISION BENEFIT PROVIDERS AND EYE 2
CARE PROVIDERS; TO DEFINE CERTAIN TERMS; TO REQUIRE CERTAIN PUBLIC 3
DISCLOSURES BY INSURERS AND VISION BENEFIT MANAGERS; TO REQUIRE 4
NOTICE TO BE PROVIDED TO PARTICIPATING EYE CARE PROVIDERS OF 5
AMENDMENTS TO AGREEMENTS AND OTHER DOCUMENTS; TO PRESCRIBE CERTAIN 6
REQUIREMENTS FOR CONTRACTS BETWEEN EYE CARE PROVIDERS AND INSURERS 7
AND VISION BENEFIT MANAGERS; TO PROHIBIT CERTAIN COERCIVE TACTICS 8
BY INSURERS AND VISION BENEFIT MANAGERS IN CONTRACTS WITH EYE CARE 9
PROVIDERS; TO PROHIBIT DIFFERENTIAL TREATMENT BY INSURERS AND 10
VISION BENEFIT MANAGERS TOWARD OPTOMETRISTS AND OPHTHALMOLOGISTS; 11
TO PROHIBIT INSURERS AND VISION BENEFIT MANAGERS FROM REQUIRING 12
PROVIDERS TO PARTICIPATE IN CERTAIN HEALTHCARE NETWORKS; TO 13
ESTABLISH CERTAIN REQUIREMENTS THAT MUST BE INCLUDED IN THE 14
PROCESS OF CREDENTIALING AND CONTRACTING WITH EYE CARE PROVIDERS; 15
TO PROHIBIT INSURERS AND VISION BENEFIT MANAGERS FROM CHANGING THE 16
TERMS OF AN AGREEMENT WITH A PARTICIPATING EYE CARE PROVIDER 17
WITHOUT CLEAR WRITTEN COMMUNICATION TO, AND ACCEPTANCE OF THE 18
CHANGES BY, THE PROVIDER; TO PROHIBIT INSURERS AND VISION BENEFIT 19
MANAGERS FROM RESTRICTING PARTICIPATING PROVIDERS FROM USING 20
CERTAIN SOURCES AND SUPPLIERS; TO PROHIBIT THE USE OF 21
EXTRAPOLATION IN AUDITING PARTICIPATING EYE CARE PROVIDERS; TO 22
AUTHORIZE AN AGGRIEVED PARTICIPATING PROVIDER TO INSTITUTE AN 23
ACTION AGAINST AN INSURER OR VISION BENEFIT PROVIDER; TO REQUIRE 24
THE INSURANCE COMMISSIONER AND DEPARTMENT OF INSURANCE, ALONG WITH 25
THE ATTORNEY GENERAL, TO ENFORCE THE PROVISIONS OF THIS ACT; TO 26
PROVIDE THAT THIS ACT APPLIES TO AN ENROLLEE'S CURRENT BENEFIT 27
PLAN UPON RENEWAL THE INITIATION OF NEW PROVIDER AGREEMENTS OR 28
AMENDMENTS TO EXISTING AGREEMENTS AFTER THE EFFECTIVE DATE OF THIS 29
ACT; AND FOR RELATED PURPOSES. 30
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 31
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SECTION 1. For purposes of this act, the following words and 32
phrases have the meanings provided in this section unless the 33
context clearly requires otherwise: 34
(a) "Chargeback" means a dollar amount, fee, surcharge, 35
rebate or item of value that reduces, modifies or offsets all or 36
part of the patient responsibility, provider reimbursement, 37
allowed amount, or fee schedule for a covered service or covered 38
material. 39
(b) "Contractual discount" means a percentage reduction 40
from a provider's usual and customary rate for covered services 41
and covered materials required under a participating provider 42
agreement. 43
(c) "Covered materials" means materials for which 44
reimbursement from an insurer, vision benefit manager, or 45
subcontractor is provided to an eye care provider by an enrollee's 46
plan contract, or for which a reimbursement would be available but 47
for the application of the enrollee's contractual limitations of 48
deductibles, copayments or coinsurance, regardless of how the 49
materials are listed or described in an enrollee's benefit plan's 50
definition of benefits. 51
(d) "Covered services" means the professional work 52
performed by an eye care provider for which reimbursement from an 53
insurer, vision benefit manager, or subcontractor is provided to 54
an eye care provider by an enrollee's plan contract, or for which 55
a reimbursement would be available but for the application of the 56
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enrollee's contractual plan limitations of deductibles, copayments 57
or coinsurance, regardless of how the services are listed or 58
described in an enrollee's benefit plan's definition of benefits. 59
(e) "De minimis" means equal to zero or an otherwise 60
negligible amount. 61
(f) "Extrapolation" means a mathematical formula, 62
process or technique used by a vision benefit manager, or the 63
vision benefit manager's agent, in the audit of an optometrist to 64
estimate audit results or findings for a larger batch or group of 65
claims not reviewed by the vision benefit manager. 66
(g) "Eye care provider" means a licensed doctor of 67
optometry practicing under the authority of Chapter 18, Title 73, 68
Mississippi Code of 1972, or a licensed medical or osteopathic 69
doctor practicing under the authority of Chapters 25 and 43, Title 70
73, Mississippi Code of 1972. 71
(h) "Fee Schedule" means the document or system that 72
lists the predetermined payment rates or allowed amounts for 73
covered services or covered materials, or both, and determines how 74
much eye care providers are reimbursed by the insurer or vision 75
benefit manager and how much patients are charged by the insurer, 76
vision benefit manager or eye care provider. 77
(i) "Health benefit plan" means a policy, contract or 78
agreement offered by an insurer, third party administrator, or 79
subcontractor to an enrollee to pay for, reimburse, discount or 80
offset health care costs. 81
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(j) "Insurer" means an individual, corporation, 82
partnership, company, organization, group, HMO, captive, 83
risk-retention group, self-insurance group, optometric service and 84
indemnity corporation or other entity, whether organized for 85
profit or not-for-profit, whether foreign or domestic, which 86
conducts business in this state and offers a vision benefit plan 87
or provides coverage for vision-related services or vision-related 88
materials to enrollees. An entity is considered an insurer 89
irrespective of: 90
(i) Its corporate form or category of licensure, 91
if applicable, including whether it is otherwise subject to 92
insurance regulations or other regulations; 93
(ii) Whether it, either directly or indirectly 94
reimburses, indemnifies, pays or discounts the costs of vision 95
services or vision materials; or 96
(iii) Whether it delegates, assigns or contracts 97
performance of any function regulated by this act to an affiliate, 98
subsidiary, contractor, intermediary or network leasing entity. 99
(k) "Materials" means ophthalmic devices, including, 100
but not limited to, lenses, devices containing lenses, artificial 101
intraocular lenses, ophthalmic frames and other lens mounting 102
apparatus, prisms, lens treatments and coatings, contact lenses, 103
low vision devices, vision therapy devices, and prosthetic devices 104
to correct, relieve or treat defects or abnormal conditions of the 105
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human eye or its adnexa, or any material allowed to be utilized by 106
the State Board of Optometry. 107
(l) "Nominal" means, when there is no corresponding 108
reimbursement in the current year's published Physician Fee 109
Schedule (PFS) released annually by the Centers for Medicare & 110
Medicaid Services (CMS) or in the current year's published state 111
Medicaid fee schedule, an amount less than the reasonable 112
compensation to the vision care provider rendering the covered 113
service or covered materials, taking into account the provider's 114
direct and indirect costs, such as the actual acquisition costs 115
and actual pro rata overhead costs, and reasonable profit. 116
(m) "Participating eye care provider" means an eye care 117
provider that has entered into a contractual agreement or other 118
business relationship with an insurer, vision benefit manager, 119
third party administrator, or subcontractor to provide covered 120
services or covered materials. 121
(n) "Subcontractor" means an individual, company, 122
organization, group or other entity, including, but not limited 123
to, agents, servants, brokers, wholesalers, distributors, 124
partially or wholly-owned subsidiaries, and controlled 125
organizations, which are contracted by the vision benefit manager 126
to supply services or materials to another vision benefit manager, 127
eye care provider or enrollee to execute or fulfill the health 128
benefit plan, vision benefit plan or vision benefit discount plan 129
of a vision benefit manager. 130
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(o) "Third party administrator" means an individual, 131
company, organization, group or other entity that provides 132
services, including, but not limited to, administrative, 133
operational, regulatory, human resource, compliance and claim 134
adjudication services for an insurer, vision benefit manager, 135
individual, company, organization, group or other entity under a 136
contract or agreement. 137
(p) "Vision benefit discount plan" means a policy, 138
contract or agreement offered by an insurer or vision benefit 139
manager to an enrollee which solely provides for a discount for 140
vision care services or materials. 141
(q) "Vision benefit manager" means an individual, 142
company, organization, group or other entity, including, but not 143
limited to insurers, third party administrators, and 144
subcontractors, which creates, promotes, sells, provides, 145
advertises or administers an integrated or stand-alone vision 146
benefit plan, vision benefit discount plan, or other insurance 147
policy or contract which provides vision benefits or discounts to 148
an enrollee pertaining to the provision of covered services or 149
covered materials. 150
(r) "Vision benefit plan" means a policy, contract or 151
agreement offered by an insurer or vision benefit manager to an 152
enrollee to pay for, reimburse or offset health and vision care 153
costs. 154
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SECTION 2. (1) An insurer or vision benefit manager shall 155
disclose the following information publicly on its internet 156
website and with all documents and document packages, including, 157
but not limited to, proposals, responses to requests for 158
proposals, sales documents, enrollment documents, benefit plan 159
documents, purchaser contracts, enrollee contracts, and provider 160
agreements, which are presented to purchasers, potential 161
purchasers, enrollees, potential enrollees, participating eye care 162
providers, potential participating providers, and state agencies 163
with jurisdictional, regulatory or enforcement authority over its 164
business: 165
(a) Its legal name and entity type; 166
(b) Its legal address and state in which the legal 167
entity is formed or organized; 168
(c) The physical address, mailing address, electronic 169
mail address and phone number of its operational headquarters; 170
(d) The agencies, departments, committees, commissions 171
and other bodies that have jurisdictional, regulatory or 172
enforcement authority over the business; 173
(e) A statement that no jurisdictional, regulatory or 174
enforcement authority exists over its business, if none exists; 175
(f) The names, physical addresses, mailing addresses, 176
email addresses and phone numbers of all parent companies, related 177
holding companies, wholly-owned subsidiary companies, and 178
partially-owned subsidiary companies; 179
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(g) All federal and state litigation in which the 180
company is or has been a party to in the current year and during 181
the preceding five (5) years. 182
(h) All Department of Insurance formal complaints 183
against the company in the current year and during the preceding 184
five (5) years by purchasers, enrollees or eye care providers. 185
(2) All information required to be disclosed by an insurer 186
or vision benefit manager in subsection (1) must be conveyed in 187
plain language and typed with a minimum of ten (10) point font 188
size and prominently displayed as follows: 189
(a) On the insurer's or vision benefit manager's 190
website in a publicly accessible section entitled "Required 191
Transparency Information for Patients, Doctors and Purchasers"; 192
and 193
(b) In a separately created document entitled "Required 194
Transparency Information for Patients, Doctors and Purchasers" 195
which must be included with all documents and document packages, 196
including, but not limited to, proposals, responses to requests 197
for proposals, benefit plan documents, sales documents, enrollment 198
documents, purchaser contracts, enrollee contracts, and provider 199
agreements. 200
(3) An insurer or vision benefit manager shall provide 201
notice to each participating eye care provider of any proposed 202
amendments to existing provider agreements, fee schedules, 203
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provider handbooks, provider manuals, or related policy documents 204
via email. 205
(4) A participating eye care provider must be provided with 206
a minimum of ninety (90) calendar days from the time of 207
distribution to review changes and respond, if necessary, to any 208
proposed amendments from an insurer or vision benefit manager to 209
existing provider agreements, fee schedules, provider handbooks, 210
provider manuals, or related policy documents. A proposed 211
amendment proffered by the insurer or vision benefit manager in 212
violation of this subsection is void and unenforceable as a matter 213
of law. 214
(5) A proposed amendment to existing provider agreements, 215
fee schedules, provider handbooks, provider manuals, or related 216
policy documents by an insurer or vision benefit manager delivered 217
to a participating eye care provider must be: 218
(a) Enumerated in a cover letter; 219
(b) Marked with highlights or in tracked changes within 220
the applicable agreements or documents, or both, to clearly 221
display all changes over the previous version(s); and 222
(c) Structured to include implications of agreement or 223
non-agreement by the participating eye care provider. 224
(6) An insurer or vision benefit manager shall maintain: 225
(a) A phone number to company representatives to 226
receive questions and communications from participating eye care 227
providers at all times during standard business hours; 228
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(b) The ability for an eye care provider to leave voice 229
messages at all times; and 230
(c) The ability for an eye care provider to have a live 231
phone discussion with a company representative within twenty-four 232
(24) hours of an initial phone call or a voice message left with 233
the insurer or vision benefit manager. 234
(7) An insurer or vision benefit manager shall maintain a 235
physical mailing address and an email address to company 236
representatives to receive questions, disputes and communications 237
from participating eye care providers about all matters, at all 238
times, including, but not limited to, proposed amendments to 239
existing provider agreements, fee schedules, provider handbooks, 240
provider manuals, and related policy documents. The insurer or 241
vision benefit manager will publish instructions for mail 242
submission and email submission of questions, disputes and 243
communications in a place visible to participating eye care 244
providers, including on its website and in any provider 245
agreements, provider handbooks, provider manuals, or related 246
policy documents. 247
(8) An insurer or vision benefit manager shall acknowledge 248
receipt of an email message within one (1) hour by use of a return 249
email message with a communication tracking number and shall 250
respond to the substantive questions or communications of the 251
email message within seventy-two (72) hours in writing by use of a 252
return email message. 253
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(9) An insurer or vision benefit manager, at all times, 254
shall make available to the eye care provider the most up-to-date 255
provider agreements, fee schedules, provider handbooks, provider 256
manuals, and related policy documents via website access. 257
(10) Insurers or vision benefit managers may not engage in 258
marketing or advertising activities that are misleading or 259
deceptive to the public. Such acts are considered deceptive trade 260
practices and subject to penalty under Section 75-24-5. 261
(11) Upon request by a state agency with jurisdictional, 262
regulatory or enforcement authority over its business, insurers 263
and vision benefit managers shall submit all information related 264
to a health benefit plan, vision benefit plan, or vision benefit 265
discount plan, including, but not limited to, proposals, responses 266
to requests for proposals, benefit plan documents, sales 267
documents, enrollment documents, purchaser contracts, enrollee 268
contracts, provider agreements, and marketing and advertising 269
activities for review. 270
SECTION 3. (1) An agreement or contract between an insurer 271
or vision benefit manager and an eye care provider may not seek to 272
or require that an eye care provider provide services or materials 273
at a fee limited or set by the insurer or vision benefit manager 274
unless the services or materials are defined and reimbursed as 275
covered services or covered materials under the agreement or 276
contract. 277
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(2) An insurer or vision benefit manager may use only 278
standardized codes, names, descriptions and definitions published 279
in the Healthcare Common Procedure Coding System (HCPCS), 280
including Current Procedural Terminology codes published by the 281
American Medical Association and Level II codes published by the 282
Centers for Medicare and Medicaid Services, to identify and 283
describe the covered services and covered materials of the vision 284
benefit plan to purchasers, enrollees and eye care providers of 285
the vision benefit plan. 286
(3) An insurer or vision benefit manager shall adhere to the 287
standardized codes, names, descriptions and definitions published 288
in the Healthcare Common Procedure Coding System (HCPCS), 289
including Current Procedural Terminology codes published by the 290
American Medical Association and Level II codes published by the 291
Centers for Medicare and Medicaid Services, to create and offer a 292
fee schedule for covered services and covered materials in an 293
agreement between the insurer or vision benefit manager and an eye 294
care provider. 295
(4) An insurer or vision benefit manager may not attempt to 296
alter the meaning of any of the standardized codes, names, 297
descriptions or definitions published in the Healthcare Common 298
Procedure Coding System (HCPCS), including Current Procedural 299
Terminology codes published by the American Medical Association 300
and Level II codes published by the Centers for Medicare and 301
Medicaid Services. Contractual language, policies or procedures 302
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set by the insurer or vision benefit manager in violation of the 303
this subsection are void and unenforceable. 304
(5) Fee schedules in an agreement between an Insurer or 305
vision benefit manager and an eye care provider and reimbursements 306
paid by an insurer or vision benefit manager to an eye care 307
provider for covered services and covered materials may not be 308
nominal or de minimis. There is no limitation on the ability of 309
an individual eye care provider or a group of eye care providers 310
who practice under a single Employer Identification Number (EIN) 311
or Tax Identification Number (TIN) to engage in direct 312
negotiations with the insurer or vision benefit manager regarding 313
reimbursement fee schedules and ultimately agreeing to a different 314
fee schedule than the fee schedule provided by the insurer or 315
vision benefit manager to other participating providers or groups. 316
(6) Fee schedule allowed amounts and reimbursements paid by 317
an insurer or vision benefit manager for each covered service and 318
covered material must be listed clearly and individually on a fee 319
schedule made available to the eye care provider: 320
(a) At the time an agreement is offered to the eye care 321
provider by an insurer or vision benefit manager; 322
(b) Within ten (10) business days from the date an 323
application is made to become a participating eye care provider 324
with the insurer or vision benefit manager by the eye care 325
provider; and 326
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(c) At all times via electronic means to the 327
participating eye care provider. 328
(7) A contract between an insurer or vision benefit manager 329
and an eye care provider must include a fee schedule that includes 330
and individually identifies each covered service and covered 331
material and its corresponding allowed amount, reimbursement 332
amount paid to the eye care provider, and any form of a 333
cost-sharing amount paid by the enrollee to the eye care provider. 334
(8) Insurers or vision benefit managers may not advertise, 335
claim or represent to purchasers or enrollees that services and 336
materials provided by a participating eye care provider are 337
covered, included or covered with an additional deductible, copay 338
or coinsurance if the insurer or vision benefit manager does not 339
remit an actual payment to the participating eye care provider as 340
full or partial reimbursement for the service or material. 341
(9) A service or material provided by a participating eye 342
care provider may not be designated as a covered service or 343
covered material by the insurer or vision benefit manager in the 344
design of a health benefit plan, vision benefit plan, or vision 345
benefit discount plan if the reimbursement amount to the 346
participating eye care provider is comprised only of an enrollee's 347
payment to the participating eye care provider. 348
(10) Insurers or vision benefit managers may not condition 349
application to or network participation in a health benefit plan, 350
vision benefit plan, or vision benefit discount plan by an eye 351
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care provider based on the eye care provider's usual and customary 352
pricing or discounts on usual and customary pricing for services 353
or materials that are not covered services or not covered 354
materials. Contractual language, policies or procedures set by 355
the insurer or vision Benefit manager in violation of this 356
subsection are void and unenforceable. 357
(11) Insurers or vision benefit managers may not make 358
conditional a fee schedule proposed or made to an eye care 359
provider of a health benefit plan, vision benefit plan, or vision 360
benefit discount plan for covered services or covered materials 361
based on the eye care provider's usual and customary pricing or 362
discounts on usual and customary pricing for services or materials 363
that are not covered services or not covered materials. 364
Contractual language, policies or procedures set by the insurer or 365
vision benefit manager in violation of this subsection are void 366
and unenforceable. 367
(12) A contract between an insurer or vision benefit manager 368
and an eye care provider may not contain a provision, fee schedule 369
or reimbursement amount in which the eye care provider, with 370
consideration of any applicable deductibles, copays, coinsurances, 371
discounts, rebates or chargebacks, agrees to provide covered 372
services or covered materials to an enrollee at a financial loss. 373
Contractual language, policies or procedures set by the insurer or 374
vision benefit manager in violation of this subsection are void 375
and unenforceable. 376
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(13) The period of time prescribed by a contract between an 377
insurer or vision benefit manager and an eye care provider for the 378
insurer or vision benefit manager to recover a reimbursement 379
amount from an eye care provider must be the same period of time 380
allowed or required for an insurer or vision benefit manager to 381
remit the applicable reimbursement following an eye care 382
provider's submission of a clean claim for services rendered or 383
materials furnished, or both. This subsection does not limit an 384
insurer or vision benefit manager's ability to conduct an audit of 385
claims, in accordance with the insurer or vision benefit manager's 386
written policies and applicable law, if the insurer or vision 387
benefit manager has a reasonable belief that the eye care provider 388
has engaged in fraud, waste or abuse. 389
(14) Insurers or vision benefit managers may not represent 390
falsely the number of participating providers in a region nor the 391
benefits that comprise a health benefit plan, vision benefit plan, 392
or vision benefit discount plan to clients, groups, employers, 393
purchasers, companies, enrollees or prospective enrollees. These 394
acts are considered deceptive trade practices and subject to 395
penalty under Section 75-24-5. 396
(15) An insurer or vision benefit manager may not promote or 397
use in marketing or advertising for a health benefit plan, vision 398
benefit plan, or vision benefit discount plan that a covered 399
service or covered material is "free," "no charge," 400
"complimentary" or any materially similar language to induce a 401
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client, group, employer, purchaser, company, enrollee or 402
prospective enrollee to purchase services, materials, supplies or 403
plans from the insurer, vision benefit manager or affiliate of the 404
insurer or vision benefit manager. 405
(16) Insurers or vision benefit managers may not offer 406
enrollees of a health benefit plan, vision benefit plan, or vision 407
benefit discount plan varying deductibles, copays, coinsurances, 408
coverage amounts, rebates, gift cards or other monetary or 409
non-monetary incentives to obtain covered services, covered 410
materials, noncovered services, or noncovered materials: 411
(a) At a particular participating eye care provider; 412
(b) At a retail establishment owned by, partially owned 413
by, contracted with, or otherwise affiliated with the insurer or 414
vision benefit manager; or 415
(c) At an Internet or virtual provider or retailer 416
owned by, partially owned by, contracted with, or otherwise 417
affiliated with the insurer or vision benefit manager. 418
(17) Insurers or vision benefit managers shall remit to the 419
participating eye care provider the contracted reimbursement 420
amount from the fee schedule for a covered service or covered 421
material provided to an enrollee if the enrollee is verified to be 422
eligible by the participating eye care provider through customary 423
verification methods of the insurer or vision benefit manager to 424
receive the covered service or covered material on the date of 425
service. 426
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(18) Insurers or vision benefit managers may not reverse a 427
reimbursement retroactively or withhold a future reimbursement to 428
a participating eye care provider who relied in good faith on an 429
individual's presented coverage credentials and the customary 430
verification methods of the insurer or vision benefit manager if 431
the vision benefit manager later determines that the enrollee was 432
ineligible to receive covered services or covered materials on the 433
date of service. 434
(19) Insurers or vision benefit managers may not require a 435
participating eye care provider, purchaser or enrollee of a health 436
benefit plan, vision benefit plan, or vision benefit discount plan 437
to obtain prior authorization, preauthorization, precertification 438
or any similar mechanism that restricts the enrollee from 439
receiving a covered service or covered material recommended by the 440
eye care provider and requested by the enrollee. 441
(20) Participating eye care providers may offer an enrollee 442
the opportunity to pay the participating eye care provider 443
directly for covered services and covered materials if the direct 444
payment would be less costly to the enrollee than the total 445
out-of-pocket cost required under the terms of a health benefit 446
plan or vision benefit plan. A provider may not be subject to an 447
audit, removed from participation in the network, or otherwise 448
penalized or discriminated against for offering an enrollee the 449
opportunity to pay the participating provider directly under the 450
conditions of this subsection. 451
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(21) Insurers or vision benefit managers may not, in the 452
course of adjudicating a claim for reimbursement by a 453
participating eye care provider for a covered service or covered 454
material, alter, delete, substitute or otherwise change a code or 455
modifier submitted by the eye care provider, including by 456
downcoding, bundling or reassigning to a different code, if the 457
change would reduce payment or otherwise adversely affect the 458
provider or enrollee, or both. For purposes of this act, 459
"downcoding" means to alter, delete, substitute or assign a code 460
that results in a lower level of service, a lower-valued code, or 461
a reduced reimbursement amount relative of the codes submitted by 462
the eye care provider; "bundling" means to combine, substitute or 463
treat two (2) or more distinct services, supplies or materials 464
reported on the same claim or date or service as included within a 465
single code, package or global service, and denying, reducing or 466
disallowing separate reimbursement for one or more of these codes. 467
(22) The provisions of this act, including applicable 468
penalties, apply to all affiliates, parent companies, third party 469
administrators, and subcontractors that are used by an insurer or 470
vision benefit manager to supply covered services or covered 471
materials to an eye care provider or enrollee. 472
(23) An insurer or vision benefit manager may not require or 473
request an eye care provider to opt-in or opt-out of the 474
provisions set forth in this act. 475
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SECTION 4. (1) An agreement between an insurer or vision 476
benefit manager and an eye care provider may not require that an 477
eye care provider participate with, be credentialed by, or enter 478
into an agreement with a specific vision benefit plan or vision 479
benefit discount plan as a condition for participation in the 480
health benefit plan provider network of the insurer or vision 481
benefit manager to provide covered services or covered materials 482
to the enrollees of the health benefit plan. 483
(2) An agreement between an insurer or vision benefit 484
manager and an eye care provider may not require that an eye care 485
provider participate with, be credentialed by, or enter into an 486
agreement with a specific health benefit plan as a condition for 487
participation in the vision benefit plan or vision benefit 488
discount plan provider network of the insurer or vision benefit 489
manager to provide covered services or covered materials to the 490
enrollees of the vision benefit plan or vision benefit discount 491
plan. 492
(3) An insurer or vision benefit manager issuing or renewing 493
a health benefit plan, vision benefit plan or vision benefit 494
discount plan that provides benefits for covered services or 495
covered materials rendered by a physician or osteopath duly 496
licensed under Chapters 25 and 43, Title 73, Mississippi Code of 497
1972, which are within the scope of practice of an optometrist 498
duly licensed under Chapter 18, Title 73, Mississippi Code of 499
1972, shall provide the same reimbursement for covered services or 500
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covered materials to optometrists as allowed for those covered 501
services or covered materials rendered by physicians or 502
osteopaths. 503
(4) An insurer or vision benefit manager shall apply the 504
same terms and conditions of participation for all eye care 505
providers, irrespective of their educational credentials, such as 506
medical doctor, osteopathic doctor or optometrist, subject to the 507
permitted scope of practice for the licensee under applicable 508
state law. 509
(5) An insurer or vision benefit manager may not require an 510
eye care provider to possess, offer, procure or sell materials or 511
covered materials in their office as a condition of participation 512
in the provider network or health benefit plan, vision benefit 513
plan, or vision benefit discount plan. Contractual language, 514
policies or procedures set by the insurer or vision benefit 515
manager in violation of this subsection is void and unenforceable. 516
(6) If an eye care provider enters into a subcontract 517
agreement with another provider to provide his or her licensed 518
health care services to an enrollee or a covered dependent of an 519
enrollee of a health benefit plan, vision benefit plan, or vision 520
benefit discount plan where the subcontracted provider will seek 521
reimbursement from the plan or enrollee for the subcontracted 522
services, the subcontract agreement must meet all requirements of 523
this act. 524
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(7) This subsection also applies to an agreement an insurer 525
or vision benefit manager enters into with another entity to 526
provide an enrollee with covered services or covered materials. 527
SECTION 5. (1) An insurer or vision benefit manager that 528
offers multiple health benefit plans, vision benefit plans, or 529
vision benefit discount plans may not require an eye care 530
provider, as a condition of participation in the network for a 531
health benefit plan, vision benefit plan or vision benefit 532
discount plan, to participate in the network of any of the 533
insurer's or vision benefit manager's other health benefit plans, 534
vision benefit plans or vision benefit discount plans. A contract 535
provision violating this subsection is void. The penalties and 536
remedies provided in this chapter for a violation of this 537
subsection do not waive, limit or otherwise affect the 538
applicability of Section 75-24-5, or any other law providing for 539
civil or criminal penalties or remedies for unfair, deceptive or 540
unlawful business practices. 541
(2) An insurer or vision benefit manager that offers 542
multiple health benefit plans, vision benefit plans, or vision 543
benefit discount plans may not withhold participation in the 544
network of one or more of the insurer's or vision benefit 545
manager's other health benefit plans, vision benefit plans, or 546
vision benefit discount plans if the eye care provider, having 547
completed the credentialing requirements of the insurer or vision 548
benefit manager for participation, already is participating in the 549
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network of one or more of the insurer's or vision benefit 550
manager's health benefit plans, vision benefit plans, or vision 551
benefit discount plans and seeks to participate in the network of 552
the insurer's or vision benefit manager's other health benefit 553
plans, vision benefit plans, or vision benefit discount plans. 554
(3) This section applies to all plan types that a health 555
benefit plan, vision benefit plan, or vision benefit discount plan 556
sells, administers or offers, including, but not limited to, 557
individually purchased plans, employer-sponsored plans, and 558
government-sponsored plans such as Medicare, Medicaid and Tricare. 559
SECTION 6. (1) An insurer or vision benefit manager must 560
include on their Internet website: (i) a method for an eye care 561
provider to submit an application for inclusion and credentialing 562
as a participating provider in the health benefit plan, vision 563
benefit plan, or vision benefit discount plan; and (ii) a 564
description of the credentialing requirements, which must be 565
reasonable, related to the delivery of covered eye care services, 566
and applied in an objective, uniform and nondiscriminatory manner. 567
(2) An insurer's or vision benefit manager's application for 568
inclusion and credentialing as a participating eye care provider 569
in the health benefit plan, vision benefit plan, or vision benefit 570
discount plan may require only standardized information prescribed 571
by the Commissioner of Insurance or information specified on the 572
Council for Affordable Quality Healthcare credentialing 573
application. 574
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(3) An insurer's or vision benefit manager's application for 575
inclusion and credentialing as a participating eye care provider 576
in the health benefit plan, vision benefit plan, or vision benefit 577
discount plan must impose the same application and credentialing 578
requirements on each eye care provider. 579
(4) No later than the ten (10) business days after the date 580
the insurer or vision benefit manager receives an application from 581
an eye care provider for inclusion and credentialing as a 582
participating provider in the health benefit plan, vision benefit 583
plan, or vision benefit discount plan, the insurer or vision 584
benefit manager shall make available electronically to the eye 585
care provider a proposed participating provider agreement, 586
including applicable fee schedules, provider handbooks, and 587
provider manuals. 588
(5) No later than the thirty (30) business days after the 589
date the insurer or vision benefit manager receives an application 590
from an eye care provider for inclusion and credentialing as a 591
participating provider in the health benefit plan, vision benefit 592
plan, or vision benefit discount plan, the insurer or vision 593
benefit manager shall complete the credentialing determination of 594
the eye care provider, approve or disapprove the application of 595
the eye care provider, and deliver electronically a proposed 596
participating provider agreement described under subsection (4) 597
for acceptance and signature of the approved eye care provider. 598
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(6) If the application for inclusion and credentialing as a 599
participating provider is denied by the insurer or vision benefit 600
manager, the insurer or vision benefit manager shall deliver to 601
the applicant eye care provider a detailed explanation for the 602
denial both electronically and in writing via certified mail. 603
(7) If the application for inclusion and credentialing as a 604
participating provider is denied by the insurer or vision benefit 605
manager, the eye care provider must be allowed a reasonable period 606
of time in which to appeal the decision to the insurer or vision 607
benefit manager and provide in the appeal evidence that supports 608
the reconsideration of the denied application. The insurer or 609
vision benefit manager shall consider, and render a decision on, 610
the eye care provider's appeal submission within thirty (30) days 611
of the date of receipt of the submission by the insurer or vision 612
benefit manager. 613
(8) If the appeal to the application denial for inclusion 614
and credentialing as a participating provider is denied by the 615
insurer or vision benefit manager, the insurer or vision benefit 616
manager shall deliver to the applicant eye care provider a 617
detailed explanation for the denial of the appeal both 618
electronically and in writing via certified mail. 619
(9) If the appeal to the application denial for inclusion 620
and credentialing as a participating provider is denied by the 621
insurer or vision benefit manager, the applicant eye care provider 622
may appeal the decision to the Commissioner of Insurance and seek 623
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a ruling that allows the eye care provider to become a 624
participating provider in the health benefit plan, vision benefit 625
plan, or vision benefit discount plan. 626
(10) An insurer or vision benefit manager, concurrent with 627
the electronic delivery of the proposed participating provider 628
agreement to the approved eye care provider described under 629
subsection (5), must provide the name, email address and phone 630
number of a representative of the insurer or vision benefit 631
manager to allow the approved eye care provider the opportunity 632
to: 633
(a) Contact the representative before signing the 634
agreement; 635
(b) Discuss the proposed agreement with the 636
representative before signing the agreement; and 637
(c) Electronically send the representative 638
modifications to the proposed agreement before signing the 639
agreement. 640
(11) If the approved eye care provider sends the 641
representative of the insurer or vision benefit manager 642
modifications to the proposed participating provider agreement 643
described under paragraph (c) of subsection (10), the insurer or 644
vision benefit manager must respond to the submission of the 645
approved eye care provider within five (5) business days. Each 646
subsequent response made by the insurer, vision benefit manager, 647
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or approved eye care provider to the other party must be responded 648
to within five (5) business days by the receiving party. 649
(12) Once the insurer or vision benefit manager has approved 650
and delivered electronically a proposed participating provider 651
agreement described under subsection (5), the approved eye care 652
provider has a total allotted timeframe of ninety (90) business 653
days to reach agreement with the insurer or vision benefit manager 654
and sign a participating provider agreement. If the parties fail 655
to reach agreement and no participating provider agreement is 656
signed by the approved eye care provider within the allotted 657
timeframe, the insurer or vision benefit manager may retract the 658
participating provider agreement. 659
(13) No later than twenty (20) business days after the date 660
the approved eye care provider signs a participating provider 661
agreement, the insurer or vision benefit manager shall include the 662
credentialed and approved eye care provider as a participating 663
provider in the health benefit plan, vision benefit plan, or 664
vision benefit discount plan and list the eye care provider in all 665
of the plan's directories that are available to enrollees and the 666
public. 667
(14) The earliest that an eye care provider may submit 668
another application to an insurer or vision benefit manager after 669
a previous approval and subsequent unsuccessful attempt to 670
negotiate a mutually acceptable participating provider agreement 671
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is one hundred eighty (180) calendar days from the date of 672
submission of the previous application. 673
(15) The earliest that an eye care provider may submit 674
another application to an insurer or vision benefit manager after 675
a previous disapproval of application is one hundred eighty (180) 676
calendar days from the date of submission of the previous 677
application. 678
(16) An insurer or vision benefit manager shall allow an eye 679
care provider to become a participating provider in the network of 680
a health benefit plan, vision benefit plan, or vision benefit 681
discount plan if the eye care provider: (i) meets the 682
credentialing requirements of the insurer or vision benefit 683
manager; and (ii) agrees in writing to the applicable provider 684
agreement. 685
(17) An insurer or vision benefit manager may not exclude an 686
eye care provider from applying to, or becoming a participating 687
provider in, the network of a health benefit plan, vision benefit 688
plan, or vision benefit discount plan because of: 689
(a) The aggregate number of eye care providers in a 690
state, county, city, zip code or other geographically defined 691
service area; 692
(b) The time, distance or appointment availability for 693
an enrollee to access a participating eye care provider; or 694
(c) The provider's professional designation, 695
independent practice affiliation, or participation status in other 696
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health benefit plans, vision benefit plans, or vision benefit 697
discount plans. 698
SECTION 7. (1) An insurer or vision benefit manager may not 699
change or alter a provider agreement, including terms, 700
reimbursements, fee schedules, policies, procedures or provider 701
manuals incorporated by reference into the provider agreement, 702
entered into with a participating eye care provider unless the 703
insurer or vision benefit manager performs the following steps at 704
least ninety (90) days before the date of the proposed change 705
would take effect: 706
(a) A certified letter, or an electronic communication 707
requiring an electronic signature proving receipt, clearly 708
detailing proposed changes is required to be sent to the eye care 709
provider; 710
(b) A face-to-face or virtual meeting is required to 711
discuss proposed changes if requested by the eye care provider; 712
(c) The eye care provider must either agree or protest 713
in writing to the proposed changes. If the changes are not agreed 714
to by the eye care provider, then the current agreement must 715
continue and the insurer or vision benefit manager may not remove 716
the eye care provider from participation with a health benefit 717
plan, vision benefit plan, or vision benefit discount plan for 718
not; 719
(d) Accepting the proposed changes; 720
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(e) A proposed amendment to an existing provider 721
agreement must be presented to the participating eye care provider 722
in a manner conducive to the eye care provider's review. Proposed 723
changes must be: (i) enumerated in a cover letter; and (ii) 724
clearly marked in tracked changes within the body of the 725
applicable agreement; and 726
(f) An agreement between an insurer or vision benefit 727
manager and an eye care provider may not contain a provision 728
requiring the optometrist to accept a reimbursement payment in the 729
form of a virtual credit card or any other payment method where a 730
processing fee, administrative fee, percentage amount, or dollar 731
amount is assessed for the provider to receive the reimbursement 732
payment. 733
(2) Termination of a provider agreement is permissible only 734
in the event of a material breach where the eye care provider 735
fails to remedy the alleged breach to the reasonable satisfaction 736
of the insurer or vision benefit manager within thirty (30) days 737
of receipt of written notice specifying the alleged breach. 738
(3) An insurer or vision benefit manager may not require an 739
eye care provider to establish a security interest in all or part 740
of their property and assets, including assets pertaining to their 741
practice, in a sum equivalent to the funds owed to the insurer or 742
vision benefit manager at termination. Contractual language, 743
policies or procedures set by the insurer or vision benefit 744
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manager in violation of this subsection are void and 745
unenforceable. 746
(4) A provider agreement between an insurer or vision 747
benefit manager and an eye care provider may not contain a 748
provision obligating the eye care provider to share equally the 749
expenses of arbitration. Contractual language, policies or 750
procedures set by the insurer or vision benefit manager in 751
violation of this subsection are void and unenforceable. Each 752
party shall bear their own arbitration costs, contingent upon a 753
fee-shifting provision that grants prevailing party status. 754
(5) An insurer or vision benefit manager may not retaliate 755
against an eye care provider for discussing, or attempting in good 756
faith to negotiate, the terms and provisions of a provider 757
agreement with the insurer or vision benefit manager. 758
(6) An insurer or vision benefit manager may not retaliate 759
against an eye care provider for filing a complaint against the 760
insurer or vision benefit manager with a state agency with 761
jurisdictional, regulatory or enforcement authority over the 762
business of the insurer or vision benefit manager. 763
(7) If retaliation by an insurer or vision benefit manager 764
occurs against an eye care provider in violation of subsection (5) 765
or (6) of this section, a state agency that has jurisdictional, 766
regulatory or enforcement authority over the business of the 767
insurer or vision benefit manager may sanction the insurer or 768
vision benefit manager, including imposition of fines and other 769
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remedies deemed appropriate, and provide an appropriate remedy for 770
the aggrieved eye care provider. 771
SECTION 8. (1) An agreement between an insurer or vision 772
benefit manager and an eye care provider may not restrict or 773
limit, either directly or indirectly, the eye care provider's 774
choice or use of sources and suppliers of covered or uncovered 775
services or materials, including the choice or use of optical 776
laboratories, provided by the eye care provider to an enrollee. 777
Contractual language, policies or procedures set by the insurer or 778
vision benefit manager in violation of this subsection are void 779
and unenforceable. 780
(2) An insurer or vision benefit manager may not, directly 781
or indirectly: 782
(a) Control or attempt to control the professional 783
judgment, manner of practice, or practice of an eye care provider; 784
(b) Employ an eye care provider to provide a covered 785
service or covered material; 786
(c) Reimburse an eye care provider a different amount 787
for covered services or covered materials because of the eye care 788
provider's choice of: 789
(i) Optical laboratory; 790
(ii) Source of supplier of: 791
1. Contact lenses; 792
2. Ophthalmic lenses; 793
3. Ophthalmic glasses frames; or 794
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4. Covered or noncovered services or 795
materials; 796
(iii) Equipment used for patient care; 797
(iv) Retail optical affiliation; 798
(v) Vision support organization; 799
(vi) Group purchasing organization; 800
(vii) Doctor alliance; 801
(vii) Professional trade association membership; 802
(viii) Electronic health record software, 803
electronic medical record software, or practice management 804
software; or 805
(ix) Third-party claim filing service, billing 806
service, or electronic data interchange clearinghouse company; 807
(d) Restrict, limit or influence an eye care provider's 808
choice of sources or suppliers of services or materials, including 809
optical laboratories used by the eye care provider to provide 810
services or materials to the enrollee; 811
(e) Restrict, limit or influence an eye care provider's 812
choice of electronic health record software, electronic medical 813
record software, or practice management software; 814
(f) Restrict, limit or influence an eye care provider's 815
choice of third-party claim filing service, billing service, or 816
electronic data interchange clearinghouse company; 817
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(g) Restrict or limit an eye care provider's access to 818
an enrollee's complete plan coverage information, including 819
in-network and out-of-network coverage details; 820
(h) Apply a chargeback to an enrollee or eye care 821
provider if the chargeback is for a covered product or service for 822
which the insurer or vision benefit manager does not incur the 823
cost to produce, deliver or provide to the enrollee or eye care 824
provider; 825
(i) Require an eye care provider to disclose an 826
enrollee's confidential or protected health information unless the 827
disclosure is authorized expressly by the enrollee or permitted 828
without authorization under the Health Insurance Portability and 829
Accountability Act of 1996; 830
(j) Require an eye care provider to disclose or report 831
a medical history or diagnosis as a condition to file a claim, 832
adjudicate a claim, or receive reimbursement for a routine or 833
wellness eye exam; 834
(k) Require an eye care provider to disclose or report 835
an enrollee's glasses prescription, contact lens prescription, 836
ophthalmic device measurements, facial photograph, or unique 837
anatomical measurements as a condition to file a claim, adjudicate 838
a claim, or receive reimbursement for a claim, unless the 839
information is needed for the vision benefit manager to 840
manufacture, or cause to be manufactured, a covered product that 841
is submitted on the applicable claim; or 842
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(l) Require an eye care provider to disclose enrollee 843
information, other than information identified on the version of 844
the Health Insurance Claim Form approved by the National Uniform 845
Claim Committee as of March 1, 2023, or its approved successor, as 846
a condition to file a claim, adjudicate a claim, or receive 847
reimbursement for a claim unless the information is needed for the 848
vision benefit manager to manufacture, or cause to be 849
manufactured, a covered product that is submitted on the 850
applicable claim. 851
(3) An insurer or vision benefit manager may not solicit 852
patients or referrals for supplies on behalf of themselves or 853
their affiliates, or both, by identifying participating eye care 854
providers in an inaccurate or otherwise misleading manner in a 855
list of participating providers or in communications to purchasers 856
or enrollees. Communications that distinguish between 857
participating eye care providers, or which otherwise claim 858
professional superiority or the performance of a professional 859
service in a superior manner, based on the following 860
characteristics, are readily subject to verification by the 861
Department of Insurance: 862
(a) A discount or incentive offered by the 863
participating eye care provider on services and materials that are 864
not covered by the insurer or vision benefit manager; 865
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(b) The dollar amount, volume amount or percent usage 866
amount of any material, product or good purchased by the 867
participating eye care provider; or 868
(c) The brand, source, manufacturer or supplier of a 869
covered service or covered material utilized by the participating 870
eye care provider. 871
(4) This section does not prohibit advertising if the 872
advertising is: (a) not false, misleading or deceptive; or (b) 873
readily subject to verification. 874
SECTION 9. An insurer or vision benefit manager may not use 875
extrapolation to complete an audit of a participating eye care 876
provider. An additional payment due to a participating eye care 877
provider or a refund due to the insurer or vision benefit manager 878
may not be based on an extrapolation but must be based on the 879
actual overpayment or underpayment, as determined after an 880
investigation by the insurer or vision benefit manager, and the 881
participating eye care provider has been afforded, and has 882
exhausted, all opportunities to appeal the insurer or vision 883
benefit manager's findings, as set forth in the provider manual or 884
policy document or applicable law, or both. 885
SECTION 10. An eye care provider adversely affected by a 886
violation of this act may bring an action in a court of competent 887
jurisdiction for injunctive relief against the insurer or vision 888
benefit manager and, upon prevailing, in addition to the 889
injunctive relief, may recover monetary damages, including, but 890
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not limited to direct, indirect, special and punitive damages, and 891
penalties of no more than Ten Thousand Dollars ($10,000.00) for 892
each violation, plus attorney's fees and costs. 893
SECTION 11. The requirements of this act are in addition to, 894
and do not limit, any other requirement applicable to an insurer 895
under state law. If there is a conflict between this act and 896
another provision of state law applicable to insurers, the 897
provision that affords greater protection to eye care providers or 898
plan enrollees are controlling. Notwithstanding any other 899
provision of law, including any law that purports to be the sole 900
body of law governing the insurer, an insurer shall comply with 901
this act to the extent not preempted by federal law. 902
SECTION 12. (1) The Commissioner of Insurance and the 903
Department of Insurance has jurisdiction to administer and enforce 904
this act with respect to any insurer and may: 905
(a) Bring an action, issue orders, and impose remedies 906
authorized by this act against any insurer; 907
(b) Adopt rules to identify activities that constitute 908
the administration, management or control of vision benefits or 909
materials; and 910
(c) Coordinate enforcement with other state agencies 911
that regulate insurers under other applicable law. The Attorney 912
General has concurrent enforcement authority for violations 913
constituting unfair or deceptive acts or practices. 914
(2) The Commissioner of Insurance shall: 915
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(a) Provide a mechanism for aggrieved individuals, 916
whether actively or formerly enrolled with a particular vision 917
care plan, to submit complaints to the commissioner for review, 918
investigation, and as appropriate, discipline under applicable 919
law. 920
(b) Enforce the state's insurance laws and this act 921
using powers granted to the commissioner under Title 83, 922
Mississippi Code of 1972; 923
(c) Ensure that insurers and vision benefit managers 924
comply with the requirement of this act; and 925
(d) Be entitled to seek an injunction against an 926
insurer or vision benefit manager in a court of competent 927
jurisdiction if the insurer or vision benefit manager: 928
(i) Issues a coverage policy that does not comply 929
with the requirements of this act, uses fraudulent, coercive or 930
dishonest practices, or demonstrates incompetence, 931
untrustworthiness or financial irresponsibility in the conduct of 932
business; 933
(ii) Fails to deal equitably with eye care 934
providers or other persons at facilities that offer services or 935
materials covered within a contract or policy issued pursuant to 936
this act; or 937
(iii) Fails to substantially comply with the 938
insurance laws of this state or violates any regulation, rule, 939
subpoena or order of the commissioner. 940
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(3) The Attorney General shall: 941
(a) Enforce the state's laws and this act's provisions, 942
using powers granted to the Attorney General under Title 83, 943
Mississippi Code of 1972, or the stat's consumer protection 944
statutes; and 945
(b) Be entitled to seek an injunction against an 946
insurer or vision benefit manager in a court of competent 947
jurisdiction. 948
(4) The penalties and remedies provided in this act for 949
violation of this act: 950
(a) Are cumulative and in addition to other penalties 951
and remedies available under state law; and 952
(b) Do not waive, limit or otherwise affect the 953
applicability of the state's consumer protection laws or any other 954
law providing for civil or criminal penalties or remedies for 955
unfair, deceptive or unlawful business practices. 956
SECTION 13. If any provision of this act or the application 957
of a provision to any person or circumstance is held invalid, the 958
remainder of the act and the application of that provision to 959
other persons or circumstances are not affected. 960
SECTION 14. (1) (a) The requirements of this section apply 961
to insurer or vision benefit manager policies, contracts, addenda 962
and certificates executed, delivered, issued for delivery, 963
continued or renewed in Mississippi. 964
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ST: Fairness in vision care; establish
requirements for contracts between insurers and
vision benefit providers and eye care providers.
(b) An insurer or vision benefit manager may not 965
construe re-credentialing as re-contracting with a participating 966
eye care provider. A provider agreement must be a distinctly 967
separate document from credentialing materials and must be signed 968
by the eye care provider and the insurer or vision benefit 969
manager. 970
(c) An insurer or vision benefit manager must include a 971
copy of the current plan provider manual referred to in a provider 972
agreement when an agreement is sent to a provider or prospective 973
provider, as well as those policies referenced in the provider 974
agreement, such as dispute resolution policies. 975
(2) This act applies to all insurers and vision benefit 976
managers upon the earlier of: 977
(a) The renewal of an enrollee's current benefit plan 978
or upon issuance of a new benefit plan to an enrollee; or 979
(b) The initiation of a new provider agreement with an 980
eye care provider or upon an amendment of an existing provider 981
agreement with an eye care provider. 982
SECTION 15. This act shall take effect and be in force from 983
and after its passage. 984