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LEGISLATURE OF NEBRASKA
ONE HUNDRED NINTH LEGISLATURE
SECOND SESSION
LEGISLATIVE BILL 987
Introduced by Lonowski, 33.
Read first time January 12, 2026
Committee: Banking, Commerce and Insurance
A BILL FOR AN ACT relating to insurance; to adopt the Vision Benefit Plan1
Act; to provide an operative date; to provide severability; and to2
declare an emergency. 3
Be it enacted by the people of the State of Nebraska,4
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Section 1. Sections 1 to 14 of this act shall be known and may be1
cited as the Vision Benefit Plan Act. 2
Sec. 2. For purposes of the Vision Benefit Plan Act:3
(1) Chargeback means a dollar amount, fee, surcharge, rebate, or4
item of value that reduces, modifies, or offsets all or part of the5
enrollee's responsibility, provider reimbursement, allowed amount, or fee6
schedule for a covered service or covered material;7
(2) Covered materials means materials for which reimbursement from8
an insurer, vision benefit manager, or subcontractor is provided to an9
eye care provider by an enrollee's plan contract, or for which a10
reimbursement would be available but for the application of the11
enrollee's contractual limitations of deductibles, copayments, or12
coinsurance, regardless of how the materials are listed or described in13
an enrollee's benefit plan's definition of benefits;14
(3) Covered services means the professional work performed by an eye15
care provider for which reimbursements for an insurer, vision benefit16
manager, or subcontractor are provided to an eye care provider by an17
enrollee's plan contract, or for which a reimbursement would be available18
but for the application of the enrollee's contractual plan limitations of19
deductibles, copayments, or coinsurance, regardless of how the services20
are listed or described in an enrollee's benefit plan's definition of21
benefits; 22
(4) Director means the Director of Insurance;23
(5) Enrollee means any individual participating in a health benefit24
plan, vision benefit plan, or vision benefit discount plan that is25
purchased by an individual or provided to an individual by an entity that26
purchases or supplies coverage for a health benefit plan, vision benefit27
plan, or vision benefit discount plan; 28
(6) Extrapolation means a mathematical formula, process, or29
technique used by a vision benefit manager, or the vision benefit30
manager's agent, in the audit of an optometrist to estimate audit results31
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or findings for a larger batch of claims not reviewed by the vision1
benefit manager; 2
(7) Eye care provider means a licensed doctor of optometry3
practicing under the authority of the Optometry Practice Act or a4
licensed medical or osteopathic doctor practicing under the authority of5
the Medicine and Surgery Practice Act; 6
(8) Fee schedule means the document or system that lists the7
predetermined payment rates or allowed amounts for covered services or8
covered materials and determines how much eye care providers are9
reimbursed by the insurer or vision benefit manager and how much patients10
are charged by the insurer, vision benefit manager, or eye care provider;11
(9) Insurer means an individual, corporation, partnership, company,12
organization, group, health maintenance organization, captive risk-13
retention group, self-insurance group, optometric service and indemnity14
corporation, or other entity, whether organized for profit or not for15
profit, whether foreign or domestic, that conducts business in this state16
and that offers a vision benefit plan or provides coverage for vision-17
related services or vision-related materials to enrollees. For avoidance18
of doubt, an entity is considered an insurer for purposes of the Vision19
Benefit Plan Act irrespective of (a) its corporate form or category of20
licensure, if applicable, including whether it is otherwise subject to21
insurance regulations or any other regulations, (b) whether it, either22
directly or indirectly, reimburses, indemnifies, pays, or discounts the23
costs of vision services or vision materials, or (c) whether it24
delegates, assigns, or contracts performance of any function regulated by25
the act to an affiliate, subsidiary, contractor, intermediary, or network26
leasing entity; 27
(10) Materials means ophthalmic devices, including, but not limited28
to, lenses, devices containing lenses, artificial intraocular lenses,29
ophthalmic frames and other lens mounting apparatus, prisms, lens30
treatments and coatings, contact lenses, low vision devices, vision31
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therapy devices, and prosthetic devices to correct, relieve, or treat1
defects or abnormal conditions of the human eye or its adnexa, or any2
material allowed to be utilized by the Board of Optometry and the3
Optometry Practice Act; 4
(11) Nominal means, when there is no corresponding reimbursement in5
the current year's published Physician Fee Schedule released annually by6
the federal Centers for Medicare and Medicaid Services or in the current7
year's published state medicaid fee schedule, an amount less than the8
reasonable compensation to the eye care provider rendering the covered9
service or covered materials, taking into account the provider's direct10
and indirect costs, including the actual acquisition costs and actual pro11
rata overhead costs and reasonable profit; 12
(12) Participating eye care provider means an eye care provider that13
has entered into a contractual agreement or other business relationship14
with an insurer, vision benefit manager, third-party administrator, or15
subcontractor to provide covered services or covered materials;16
(13) Subcontractor means an individual, company, organization,17
group, or other entity, including, but not limited to, agents, servants,18
brokers, wholesalers, distributors, partially owned or wholly owned19
subsidiaries, and controlled organizations, that is contracted by the20
vision benefit manager to supply services or materials to another vision21
benefit manager, eye care provider, or enrollee to execute or fulfill the22
health benefit plan, vision benefit plan, or vision benefit discount plan23
of a vision benefit manager; 24
(14) Vision benefit discount plan means a policy, contract, or25
agreement offered by an insurer or vision benefit manager to an enrollee26
that solely provides for a discount for vision care services or27
materials; 28
(15) Vision benefit manager means an individual, company,29
organization, group, or other entity, including, but not limited to, an30
insurer, a third-party administrator, and a subcontractor, that creates,31
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promotes, sells, provides, advertises, or administers an integrated or1
stand-alone vision benefit plan, vision benefit discount plan, or other2
insurance policy or contract which provides vision benefits or discounts3
to an enrollee pertaining to the provision of covered services or covered4
materials; and 5
(16) Vision benefit plan means a policy, contract, agreement, or any6
prepaid vision plan offered by an insurer or vision benefit manager to an7
enrollee to pay for, reimburse, discount, or offset healthcare costs.8
Sec. 3. (1) An insurer or vision benefit manager shall disclose the9
following information publicly on its website and with all documents and10
document packages, including, but not limited to, proposals, responses to11
requests for proposals, sales documents, enrollment documents, benefit12
plan documents, purchaser contracts, enrollee contracts, and provider13
agreements that are presented to purchasers, potential purchasers,14
enrollees, potential enrollees, participating eye care providers,15
potential participating providers, and state agencies with16
jurisdictional, regulatory, or enforcement authority over its business:17
(a) Its legal name and entity type; 18
(b) Its legal address and the state in which the legal entity is19
formed or organized; 20
(c) The physical address, mailing address, electronic mail address,21
and phone number of its operational headquarters; 22
(d) The agencies, departments, committees, commissions, and other23
bodies that have jurisdictional, regulatory, or enforcement authority24
over its business; 25
(e) A statement that no jurisdictional, regulatory, or enforcement26
authority exists over its business, if none exists;27
(f) The names, physical addresses, mailing addresses, electronic28
mail addresses, and phone numbers of all parent companies, related29
holding companies, wholly owned subsidiary companies, and partially owned30
subsidiary companies; 31
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(g) All federal and state litigation in which the insurer or vision1
benefit manager is, or has been, a party in the current year and during2
the preceding five years; and 3
(h) All formal complaints to the Department of Insurance against the4
insurer or vision benefit manager in the current year and during the5
preceding five years by purchasers, enrollees, or eye care providers.6
(2) All information required to be disclosed by an insurer or vision7
benefit manager in subsection (1) of this section shall be conveyed in8
plain language, shall be typed with a minimum of ten-point font size, and9
shall be prominently displayed: 10
(a) On the insurer's or vision benefit manager's website in a11
publicly accessible section titled "Required Transparency Information for12
Patients, Doctors, and Purchasers"; and 13
(b) In a separately created document titled "Required Transparency14
Information for Patients, Doctors, and Purchasers" that shall be included15
with all documents and document packages, including, but not limited to,16
proposals, responses to requests for proposals, benefit plan documents,17
sales documents, enrollment documents, purchaser contracts, enrollee18
contracts, and provider agreements. 19
(3) An insurer or vision benefit manager shall provide notice to20
each participating eye care provider of any proposed amendments to21
existing provider agreements, fee schedules, provider handbooks, provider22
manuals, or related policy documents via electronic mail.23
(4) A participating eye care provider shall be provided with a24
minimum of ninety calendar days from the time of distribution to review25
changes and respond, if necessary, to any proposed amendments from an26
insurer or vision benefit manager to existing provider agreements, fee27
schedules, provider handbooks, provider manuals, or related policy28
documents. Any such proposed amendments proffered by the insurer or29
vision benefit manager in violation of this subsection shall be void and30
unenforceable as a matter of law. 31
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(5) Any proposed amendments to existing provider agreements, fee1
schedules, provider handbooks, provider manuals, or related policy2
documents by an insurer or vision benefit manager delivered to a3
participating eye care provider shall be: 4
(a) Enumerated in a cover letter; 5
(b) Marked with highlights or in tracked changes within the6
applicable agreements or documents to clearly display all changes over7
the previous version; and 8
(c) Structured to include implications of agreeance or non-agreeance9
by the participating eye care provider. 10
(6) An insurer or vision benefit manager shall maintain:11
(a) A phone number to company representatives to receive questions12
and communications from participating eye care providers at all times13
during standard business hours; 14
(b) The ability for an eye care provider to leave voice messages at15
all times; and 16
(c) The ability for an eye care provider to have a live phone17
discussion with a company representative within twenty-four hours of an18
initial phone call or a voice message left with the insurer or vision19
benefit manager. 20
(7) An insurer or vision benefit manager shall maintain a physical21
mailing address and an electronic mail address to company representatives22
to receive questions, disputes, and communications from participating eye23
care providers about all matters, at all times, including, but not24
limited to, proposed amendments to existing provider agreements, fee25
schedules, provider handbooks, provider manuals, and related policy26
documents, and shall publish instructions for mail submission and27
electronic mail submission of questions, disputes, and communications in28
a place visible to participating eye care providers, including on its29
website and in any provider agreements, provider handbooks, provider30
manuals, or related policy documents. 31
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(8) An insurer or vision benefit manager shall acknowledge receipt1
of an electronic mail message within one hour by use of a return2
electronic mail message with a communication tracking number and shall3
respond to the substantive questions or communications of the electronic4
mail message within seventy-two hours in writing by use of a return5
electronic mail message. 6
(9) An insurer or vision benefit manager shall, at all times, make7
available to the eye care provider the most up-to-date provider8
agreements, fee schedules, provider handbooks, provider manuals, and9
related policy documents via website access. 10
(10) Insurers or vision benefit managers shall not engage in11
marketing or advertising activities that are misleading or deceptive to12
the public. Such acts are considered deceptive trade practices and13
subject to penalty under the Uniform Deceptive Trade Practices Act.14
(11) Upon request by a state agency with jurisdictional, regulatory,15
or enforcement authority over its business, an insurer or vision benefit16
manager shall submit all information related to a health benefit plan,17
vision benefit plan, or vision benefit discount plan, including, but not18
limited to, proposals, responses to requests for proposals, benefit plan19
documents, sales documents, enrollment documents, purchaser contracts,20
enrollee contracts, provider agreements, and marketing and advertising21
activities, for review. 22
Sec. 4. (1) No agreement or contract between an insurer or vision23
benefit manager and an eye care provider may seek to or require that an24
eye care provider provide services or materials at a fee limited or set25
by the insurer or vision benefit manager unless the services or materials26
are defined and reimbursed as covered services or covered materials under27
the agreement or contract. 28
(2) An insurer or vision benefit manager shall only use standardized29
codes, names, descriptions, and definitions published in the Healthcare30
Common Procedure Coding System, including Current Procedural Terminology31
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codes published by the American Medical Association and Level II codes1
published by the federal Centers for Medicare and Medicaid Services, to2
identify and describe covered services and covered materials of the3
vision benefit plan to purchasers, enrollees, and eye care providers of4
the vision benefit plan. 5
(3) An insurer or vision benefit manager shall adhere to the6
standardized codes, names, descriptions, and definitions published in the7
Healthcare Common Procedure Coding System, including all Current8
Procedural Terminology codes published by the American Medical9
Association and all Level II codes published by the federal Centers for10
Medicare and Medicaid Services, to create and offer a fee schedule for11
covered services and covered materials in an agreement between the12
insurer or vision benefit manager and an eye care provider.13
(4) An insurer or vision benefit manager shall not attempt to alter14
the meaning of any of the standardized codes, names, descriptions, or15
definitions published in the Healthcare Common Procedure Coding System,16
including all Current Procedural Terminology codes published by the17
American Medical Association and all Level II codes published by the18
federal Centers for Medicare and Medicaid Services. Any such contractual19
language, policies, or procedures set by the insurer or vision benefit20
manager in violation of this subsection shall be void and unenforceable21
as a matter of law. 22
(5) All fee schedules in an agreement between an insurer or vision23
benefit manager and an eye care provider and all reimbursements paid by24
an insurer or vision benefit manager to an eye care provider for all25
covered services and covered materials shall not be nominal or de26
minimis. There shall be no limitation on the ability of an individual eye27
care provider or a group of eye care providers who practice under a28
single employer identification number or tax identification number to29
engage in direct negotiations with the insurer or vision benefit manager30
regarding reimbursement fee schedules and ultimately agreeing to a31
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different fee schedule than the fee schedule provided by the insurer or1
vision benefit manager to other participating providers or groups.2
(6) All fee schedule allowed amounts and all reimbursements paid by3
an insurer or vision benefit manager for each covered service and covered4
material shall be clearly and individually listed on a fee schedule made5
available to the eye care provider: 6
(a) At the time an agreement is offered to the eye care provider by7
an insurer or vision benefit manager; 8
(b) Within fifteen business days from the date an application is9
made to become a participating eye care provider with the insurer or10
vision benefit manager by the eye care provider; and11
(c) At all times via electronic means to the participating eye care12
provider. 13
(7) A contract between an insurer or vision benefit manager and an14
eye care provider shall include a fee schedule that includes and15
individually identifies each covered service and covered material and its16
corresponding allowed amount, reimbursement amount paid to the eye care17
provider, and any form of a cost-sharing amount paid by the enrollee to18
the eye care provider. 19
(8) Insurers or vision benefit managers shall not advertise, claim,20
or represent to purchasers or enrollees that services and materials21
provided by a participating eye care provider are covered, included, or22
covered with an additional deductible, copay, or coinsurance if the23
insurer or vision benefit manager does not remit an actual payment to the24
participating eye care provider as full or partial reimbursement for the25
service or material. 26
(9) A service or material provided by a participating eye care27
provider cannot be designated as a covered service or covered material by28
the insurer or vision benefit manager in the design of a health benefit29
plan, vision benefit plan, or vision benefit discount plan if the30
reimbursement amount to the participating eye care provider is only31
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comprised of an enrollee's payment to the participating eye care1
provider. 2
(10) Insurers or vision benefit managers shall not condition3
application to or network participation in a health benefit plan, vision4
benefit plan, or vision benefit discount plan by an eye care provider5
based on the eye care provider's usual and customary pricing or discounts6
on usual and customary pricing for services or materials that are not7
covered services or not covered materials. Any such contractual language,8
policies, or procedures set by the insurer or vision benefit manager in9
violation of this subsection shall be void and unenforceable as a matter10
of law. 11
(11) Insurers or vision benefit managers shall not make conditional12
a fee schedule proposed or made to an eye care provider of a health13
benefit plan, vision benefit plan, or vision benefit discount plan for14
covered services or covered materials based on the eye care provider's15
usual and customary pricing or discounts on usual and customary pricing16
for services or materials that are not covered services or not covered17
materials. Any such contractual language, policies, or procedures set by18
the insurer or vision benefit manager in violation of this subsection19
shall be void and unenforceable as a matter of law.20
(12) A contract between an insurer or vision benefit manager and an21
eye care provider shall not contain a provision, fee schedule, or22
reimbursement amount in which the eye care provider, with consideration23
of any applicable deductibles, copays, coinsurances, discounts, rebates,24
or chargebacks, provides covered services or covered materials to an25
enrollee at a financial loss. Any such contractual language, policies, or26
procedures set by the insurer or vision benefit manager in violation of27
this subsection shall be void and unenforceable as a matter of law.28
(13) The period of time prescribed by a contract between any insurer29
or vision benefit manager and an eye care provider for the insurer or30
vision benefit manager to recover any reimbursement amount from an eye31
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care provider shall be the same period of time allowed or required for1
any insurer or vision benefit manager to remit the applicable2
reimbursement following an eye care provider's submission of a clean3
claim for services rendered or materials furnished. This subsection shall4
not limit the ability of an insurer or vision benefit manager to conduct5
an audit of claims, in accordance with the insurer's or vision benefit6
manager's written policies and applicable law, in the event that the7
insurer or vision benefit manager has a reasonable belief that the eye8
care provider has engaged in fraud, waste, or abuse.9
(14) Insurers or vision benefit managers shall not falsely represent10
the number of participating providers in a region or the benefits that11
comprise a health benefit plan, vision benefit plan, or vision benefit12
discount plan to clients, groups, employers, purchasers, companies,13
enrollees, or prospective enrollees. Such acts are considered deceptive14
trade practices and subject to penalty under the Uniform Deceptive Trade15
Practices Act. 16
(15) An insurer or vision benefit manager shall not promote or use17
in any marketing or advertising for a health benefit plan, vision benefit18
plan, or vision benefit discount plan that a covered service or covered19
material is free, no charge, complimentary, or any materially similar20
language to induce a client, group, employer, purchaser, company,21
enrollee, or prospective enrollee to purchase services, materials,22
supplies, or plans from the insurer, vision benefit manager, or an23
affiliate of the insurer or vision benefit manager.24
(16) Insurers or vision benefit managers shall not offer enrollees25
of a health benefit plan, vision benefit plan, or vision benefit discount26
plan varying deductibles, copays, coinsurances, coverage amounts,27
rebates, gift cards, or other monetary or nonmonetary incentives to28
obtain covered services, covered materials, noncovered services, or29
noncovered materials: 30
(a) At any particular participating eye care provider;31
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(b) At a retail establishment owned by, partially owned by,1
contracted with, or otherwise affiliated with the insurer or vision2
benefit manager; or 3
(c) At any Internet or virtual provider or retailer owned by,4
partially owned by, contracted with, or otherwise affiliated with the5
insurer or vision benefit manager. 6
(17) Insurers or vision benefit managers shall remit to the7
participating eye care provider the contracted reimbursement amount from8
the fee schedule for a covered service or covered material provided to an9
enrollee if the enrollee is verified to be eligible by the participating10
eye care provider through customary verification methods of the insurer11
or vision benefit manager to receive the covered service or covered12
material on the date of service. 13
(18) Insurers or vision benefit managers shall not retroactively14
reverse a reimbursement or withhold a future reimbursement to a15
participating eye care provider who relied in good faith on an16
individual's presented coverage credentials and the customary17
verification methods of the insurer or vision benefit manager if the18
vision benefit manager later determines that the enrollee was ineligible19
to receive covered services or covered materials on the date of service.20
(19) Insurers or vision benefit managers shall not require a21
participating eye care provider, purchaser, or enrollee of a health22
benefit plan, vision benefit plan, or vision benefit discount plan to23
obtain prior authorization, preauthorization, precertification, or any24
similar mechanism that restricts the enrollee from receiving a covered25
service or covered material recommended by the eye care provider and26
requested by the enrollee. 27
(20) Participating eye care providers are allowed, but not required,28
to offer an enrollee the opportunity to pay the participating eye care29
provider directly for covered services and covered materials if such30
direct payment would be less costly to the enrollee than the total out-31
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of-pocket cost required under the terms of a health benefit plan or1
vision benefit plan. A provider may not be subject to an audit, removed2
from participation in the network, or otherwise penalized or3
discriminated against in any manner for offering an enrollee the4
opportunity to pay the participating provider directly under the5
conditions described in this subsection. 6
(21)(a) Insurers or vision benefit managers shall not, in the course7
of adjudicating a claim for reimbursement by a participating eye care8
provider for a covered service or covered material, alter, delete,9
substitute, or otherwise change any code or modifier submitted by the eye10
care provider, including by downcoding, bundling, or reassigning to a11
different code, if such change would reduce payment or otherwise12
adversely affect the provider or enrollee. 13
(b) For purposes of this subsection: 14
(i) Bundling means to combine, substitute, or treat two or more15
distinct services, supplies, or materials reported on the same claim or16
date of service as included within a single code, package, or global17
service, and denying, reducing, or disallowing separate reimbursement for18
one or more of these codes; and 19
(ii) Downcoding means to alter, delete, substitute, or assign a code20
that results in a lower level of service, a lower-valued code, or a21
reduced reimbursement amount relative to the code submitted by the eye22
care provider. 23
(22) All provisions of this section shall apply to all affiliates,24
parent companies, third-party administrators, and subcontractors that are25
used by an insurer or vision benefit manager to supply covered services26
or covered materials to an eye care provider or enrollee, and such27
affiliates, parent companies, third-party administrators, and28
subcontractors shall be subject to all applicable penalties as provided29
in this section. 30
(23) An insurer or vision benefit manager shall not require or31
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request an eye care provider to opt in or opt out of the provisions set1
forth in the Vision Benefit Plan Act. 2
Sec. 5. (1) No agreement between an insurer or vision benefit3
manager and an eye care provider shall require that an eye care provider4
must participate with, be credentialed by, or enter into an agreement5
with any specific vision benefit plan or vision benefit discount plan as6
a condition for participation in the health benefit plan provider network7
of the insurer or vision benefit manager to provide covered services or8
covered materials to the enrollees of the health benefit plan.9
(2) No agreement between an insurer or vision benefit manager and an10
eye care provider shall require that an eye care provider must11
participate with, be credentialed by, or enter into an agreement with any12
specific health benefit plan as a condition for participation in the13
vision benefit plan or vision benefit discount plan provider network of14
the insurer or vision benefit manager to provide covered services or15
covered materials to the enrollees of the vision benefit plan or vision16
benefit discount plan. 17
(3) Any insurer or vision benefit manager issuing or renewing a18
health benefit plan, vision benefit plan, or vision benefit discount plan19
which provides benefits for covered services or covered materials20
rendered by a physician or osteopath duly licensed under the Medicine and21
Surgery Practice Act that are within the scope of practice of an22
optometrist duly licensed under the Optometry Practice Act shall provide23
the same reimbursement for covered services or covered materials to24
optometrists as allowed for those covered services or covered materials25
rendered by physicians or osteopaths. 26
(4) An insurer or vision benefit manager shall apply the same terms27
and conditions of participation for all eye care providers, irrespective28
of their educational credentials, subject to the permitted scope of29
practice for the provider under applicable state law.30
(5) An insurer or vision benefit manager shall not require an eye31
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care provider to possess, offer, procure, or sell materials or covered1
materials in the provider's office as a condition of participation in the2
provider network of the health benefit plan, vision benefit plan, or3
vision benefit discount plan. Any such contractual language, policies, or4
procedures set by the insurer or vision benefit manager in violation of5
this subsection shall be void and unenforceable as a matter of law.6
(6) If an eye care provider enters into any subcontract agreement7
with another provider to provide his or her licensed health care services8
to an enrollee or a covered dependent of an enrollee of a health benefit9
plan, vision benefit plan, or vision benefit discount plan where the10
subcontracted provider will seek reimbursement from the plan or enrollee11
for the subcontracted services, the subcontract agreement must meet all12
requirements of the Vision Benefit Plan Act. 13
(7) The provisions of this section shall apply to any agreements an14
insurer or vision benefit manager enters into with another entity to15
provide an enrollee with covered services or covered materials.16
Sec. 6. (1) It is prohibited for an insurer or vision benefit17
manager that offers multiple health benefit plans, vision benefit plans,18
or vision benefit discount plans to require an eye care provider, as a19
condition of participation in the network for a health benefit plan,20
vision benefit plan, or vision benefit discount plan, to participate in21
the network of any of the insurer's or vision benefit manager's other22
health benefit plans, vision benefit plans, or vision benefit discount23
plans. A contract provision violating this subsection is void as a matter24
of law. 25
(2) It is prohibited for an insurer or vision benefit manager that26
offers multiple health benefit plans, vision benefit plans, or vision27
benefit discount plans to withhold participation in the network of one or28
more of the insurer's or vision benefit manager's other health benefit29
plans, vision benefit plans, or vision benefit discount plans if the eye30
care provider, having completed the credentialing requirements of the31
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insurer or vision benefit manager for participation, is already1
participating in the network of one or more of the insurer's or vision2
benefit manager's health benefit plans, vision benefit plans, or vision3
benefit discount plans and seeks to participate in the network of the4
insurer's or vision benefit manager's other health benefit plans, vision5
benefit plans, or vision benefit discount plans. 6
(3) Subsections (1) and (2) of this section apply to all plan types7
that a health benefit plan, vision benefit plan, or vision benefit8
discount plan sells, administers, or offers, including, but not limited9
to, individually purchased plans, employer-sponsored plans, and10
government-sponsored plans. 11
Sec. 7. (1) An insurer or vision benefit manager shall include on12
its website: 13
(a) A method for an eye care provider to submit an application for14
inclusion and credentialing as a participating provider in the health15
benefit plan, vision benefit plan, or vision benefit discount plan; and16
(b) A description of the credentialing requirements, which must be17
reasonable, related to the delivery of covered eye care services, and18
applied in an objective, uniform, and nondiscriminatory manner.19
(2) An insurer's or vision benefit manager's application for20
inclusion and credentialing as a participating eye care provider in the21
health benefit plan, vision benefit plan, or vision benefit discount plan22
must impose the same application and credentialing requirements on each23
eye care provider. 24
(3) No later than the tenth business day after the date the insurer25
or vision benefit manager receives an application from an eye care26
provider for inclusion and credentialing as a participating provider in27
the health benefit plan, vision benefit plan, or vision benefit discount28
plan, the insurer or vision benefit manager shall make available29
electronically to the eye care provider a proposed participating provider30
agreement, including applicable fee schedules, provider handbooks, and31
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provider manuals. 1
(4) No later than the thirtieth business day after the date the2
insurer or vision benefit manager receives an application from an eye3
care provider for inclusion and credentialing as a participating provider4
in the health benefit plan, vision benefit plan, or vision benefit5
discount plan, the insurer or vision benefit manager shall complete the6
credentialing determination of the eye care provider, approve or7
disapprove the application of the eye care provider, and deliver8
electronically a proposed participating provider agreement described in9
subsection (3) of this section for acceptance and signature of the10
approved eye care provider. 11
(5) If the application for inclusion and credentialing as a12
participating provider is denied by the insurer or vision benefit13
manager, the insurer or vision benefit manager shall deliver to the14
applicant eye care provider a detailed explanation for the denial both15
electronically and in writing via certified mail. 16
(6) If the application for inclusion and credentialing as a17
participating provider is denied by the insurer or vision benefit18
manager, the eye care provider must be allowed a reasonable period of19
time in which to appeal the decision to the insurer or vision benefit20
manager and provide in the appeal evidence that supports the21
reconsideration of the denied application. The insurer or vision benefit22
manager shall consider, and render a decision on, the eye care provider's23
appeal submission within thirty days of the date of receipt of the24
submission by the insurer or vision benefit manager.25
(7) If the appeal of the application denial for inclusion and26
credentialing as a participating provider is denied by the insurer or27
vision benefit manager, the insurer or vision benefit manager shall28
deliver to the applicant eye care provider a detailed explanation for the29
denial of the appeal both electronically and in writing via certified30
mail. 31
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(8) An insurer or vision benefit manager, concurrent with the1
electronic delivery of the proposed participating provider agreement to2
the approved eye care provider pursuant to subsection (4) of this3
section, must provide the name, email address, and phone number of a4
representative of the insurer or vision benefit manager to allow the5
approved eye care provider the opportunity to: 6
(a) Contact the representative before signing the agreement;7
(b) Discuss the proposed agreement with the representative before8
signing the agreement; and 9
(c) Electronically send the representative modifications to the10
proposed agreement before signing the agreement. 11
(9) In the event that the approved eye care provider sends the12
representative of the insurer or vision benefit manager modifications to13
the proposed participating provider agreement pursuant to subdivision (8)14
(c) of this section, the insurer or vision benefit manager must respond15
to the submission of the approved eye care provider within five business16
days. Each subsequent response made by the insurer, vision benefit17
manager, or approved eye care provider to the other party must be18
responded to within five business days by the receiving party.19
(10) Once the insurer or vision benefit manager has approved and20
delivered electronically a proposed participating provider agreement21
pursuant to subsection (4) of this section, the approved eye care22
provider has a total allotted timeframe of ninety business days to reach23
agreement with the insurer or vision benefit manager and sign a24
participating provider agreement. If the parties fail to reach agreement25
and no participating provider agreement is signed by the approved eye26
care provider within the allotted timeframe, the insurer or vision27
benefit manager may retract the participating provider agreement.28
(11) No later than the twentieth business day after the date the29
approved eye care provider signs a participating provider agreement, the30
insurer or vision benefit manager shall include the credentialed and31
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approved eye care provider as a participating provider in the health1
benefit plan, vision benefit plan, or vision benefit discount plan and2
list the eye care provider in all of the plan's directories that are3
available to enrollees and the public. 4
(12) The earliest that an eye care provider may submit another5
application to an insurer or vision benefit manager after a previous6
approval and subsequent unsuccessful attempt to negotiate a mutually7
acceptable participating provider agreement is one hundred eighty8
calendar days from the date of submission of the previous application.9
(13) The earliest that an eye care provider may submit another10
application to an insurer or vision benefit manager after a previous11
disapproval of an application is one hundred eighty calendar days from12
the date of submission of the previous application.13
(14) An insurer or vision benefit manager shall allow an eye care14
provider to become a participating provider in the network of a health15
benefit plan, vision benefit plan, or vision benefit discount plan if the16
eye care provider (a) meets the credentialing requirements of the insurer17
or vision benefit manager and (b) agrees in writing to the applicable18
provider agreement. 19
(15) An insurer or vision benefit manager shall not exclude an eye20
care provider from applying to, or becoming a participating provider in,21
the network of a health benefit plan, vision benefit plan, or vision22
benefit discount plan because of: 23
(a) The aggregate number of eye care providers in a state, county,24
city, zip code, or other geographically defined service area;25
(b) The time, distance, or appointment availability for an enrollee26
to access a participating eye care provider; or 27
(c) The provider's professional designation, independent practice28
affiliation, or participation status in other health benefit plans,29
vision benefit plans, or vision benefit discount plans.30
Sec. 8. (1) An insurer or vision benefit manager shall not change31
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or alter a provider agreement, including terms, reimbursements, fee1
schedules, policies, procedures, or provider manuals incorporated by2
reference into the provider agreement, entered into with a participating3
eye care provider unless the insurer or vision benefit manager performs4
the following steps at least ninety days before the date the proposed5
change would take effect: 6
(a) A certified letter, or an electronic communication requiring an7
electronic signature proving receipt, clearly detailing the proposed8
changes must be sent to the eye care provider; 9
(b) A face-to-face or virtual meeting must be held to discuss10
proposed changes if requested by the eye care provider;11
(c) The eye care provider must either agree to or protest in writing12
the proposed changes. If the changes are not agreed to by the eye care13
provider, then the current agreement shall continue and the insurer or14
vision benefit manager shall not remove the eye care provider from15
participation with a health benefit plan, vision benefit plan, or vision16
benefit discount plan for not accepting the proposed changes; and17
(d) Any proposed amendment to an existing provider agreement must be18
presented to the participating eye care provider in a manner conducive to19
the eye care provider's review. The proposed changes shall be (i)20
enumerated in a cover letter and (ii) clearly marked in tracked changes21
within the body of the applicable agreement. 22
(2) Termination of any provider agreement shall be permissible only23
in the event of a material breach, wherein the eye care provider fails to24
remedy the alleged breach to the reasonable satisfaction of the insurer25
or vision benefit manager within thirty days of receipt of written notice26
specifying the alleged breach. 27
(3) It shall be prohibited for an insurer or vision benefit manager28
to require an eye care provider to establish a security interest in all29
or part of the provider's property and assets, including assets30
pertaining to the provider's practice, in a sum equivalent to the funds31
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owed to the insurer or vision benefit manager at termination. Any such1
contractual language, policies, or procedures set by the insurer or2
vision benefit manager in violation of this subsection shall be void and3
unenforceable as a matter of law. 4
(4) A provider agreement between an insurer or vision benefit5
manager and an eye care provider shall not contain a provision requiring6
the provider to accept a reimbursement payment in the form of a virtual7
credit card or any other payment method wherein a processing fee,8
administrative fee, percentage amount, or dollar amount is assessed for9
the provider to receive the reimbursement payment.10
(5) A provider agreement between an insurer or vision benefit11
manager and an eye care provider shall not contain a provision obligating12
the eye care provider to share equally the expenses of arbitration. Any13
such contractual language, policies, or procedures set by the insurer or14
vision benefit manager in violation of this subsection shall be void and15
unenforceable as a matter of law. Each party shall bear their own16
arbitration costs, contingent upon a fee-shifting provision that grants17
prevailing party status. 18
(6) An insurer or vision benefit manager shall not retaliate in any19
manner against an eye care provider for discussing, or attempting in good20
faith to negotiate, the terms and provisions of a provider agreement with21
the insurer or vision benefit manager. 22
(7) An insurer or vision benefit manager shall not retaliate in any23
manner against an eye care provider for filing a complaint against the24
insurer or vision benefit manager with any state agency with25
jurisdictional, regulatory, or enforcement authority over the business of26
the insurer or vision benefit manager. 27
(8) Should retaliation by an insurer or vision benefit manager occur28
against an eye care provider in violation of subsection (6) or (7) of29
this section, a state agency that has jurisdictional, regulatory, or30
enforcement authority over the business of the insurer or vision benefit31
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manager may sanction the insurer or vision benefit manager, including1
fines and other remedies deemed appropriate, and provide an appropriate2
remedy for the aggrieved eye care provider. 3
Sec. 9. (1) No agreement between an insurer or vision benefit4
manager and an eye care provider shall restrict or limit, either directly5
or indirectly, the eye care provider's choice or use of sources and6
suppliers of covered or uncovered services or materials, including the7
choice or use of optical laboratories, provided by the eye care provider8
to an enrollee. Any such contractual language, policies, or procedures9
set by the insurer or vision benefit manager in violation of this10
subsection shall be void and unenforceable as a matter of law.11
(2) An insurer or vision benefit manager shall not directly or12
indirectly: 13
(a) Control or attempt to control the professional judgment, manner14
of practice, or practice of an eye care provider; 15
(b) Employ an eye care provider to provide a covered service or16
covered material; 17
(c) Reimburse an eye care provider a different amount for covered18
services or covered materials because of the eye care provider's choice19
of: 20
(i) Optical laboratory; 21
(ii) Source of supplier of: 22
(A) Contact lenses; 23
(B) Ophthalmic lenses; 24
(C) Ophthalmic glasses frames; or 25
(D) Covered or noncovered services or materials;26
(iii) Equipment used for patient care; 27
(iv) Retail optical affiliation; 28
(v) Vision support organization; 29
(vi) Group purchasing organization; 30
(vii) Doctor alliance; 31
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(viii) Professional trade association membership;1
(ix) Electronic health record software, electronic medical record2
software, or practice management software; or 3
(x) Third-party claim filing service, billing service, or electronic4
data interchange clearinghouse company; 5
(d) Restrict, limit, or influence an eye care provider's choice of6
sources or suppliers of services or materials, including optical7
laboratories used by the eye care provider to provide services or8
materials to the enrollee; 9
(e) Restrict, limit, or influence an eye care provider's choice of10
electronic health record software, electronic medical record software, or11
practice management software; 12
(f) Restrict, limit, or influence an eye care provider's choice of13
third-party claim filing service, billing service, or electronic data14
interchange clearinghouse company; 15
(g) Restrict or limit an eye care provider's access to an enrollee's16
complete plan coverage information, including in-network and out-of-17
network coverage details; 18
(h) Apply a chargeback to an enrollee or eye care provider if the19
chargeback is for a covered product or service for which the insurer or20
vision benefit manager does not incur the cost to produce, deliver, or21
provide such product or service to the enrollee or eye care provider;22
(i) Require an eye care provider to disclose an enrollee's23
confidential or protected health information unless the disclosure is24
expressly authorized by the enrollee, or permitted without authorization25
under the Health Insurance Portability and Accountability Act of 1996;26
(j) Require an eye care provider to disclose or report a medical27
history or diagnosis as a condition to file a claim, adjudicate a claim,28
or receive reimbursement for a routine or wellness eye exam; or29
(k) Require an eye care provider to disclose or report an enrollee's30
glasses prescription, contact lens prescription, ophthalmic device31
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measurements, facial photograph, or unique anatomical measurements as a1
condition to file a claim, adjudicate a claim, or receive reimbursement2
for a claim, unless the information is needed for the vision benefit3
manager to manufacture, or cause to be manufactured, a covered product4
that is submitted on the applicable claim. 5
(3) An insurer or vision benefit manager shall not solicit patients6
or referrals for supplies on behalf of itself or its affiliates by7
identifying participating eye care providers in an inaccurate or8
otherwise misleading manner in any list of participating providers or in9
any communications to purchasers or enrollees. All communications which10
distinguish between participating eye care providers, or which otherwise11
claim professional superiority or the performance of a professional12
service in a superior manner, based on the following characteristics13
shall be readily subject to verification by the Department of Insurance:14
(a) A discount or incentive offered by the participating eye care15
provider on services and materials that are not covered by the insurer or16
vision benefit manager; 17
(b) The dollar amount, volume amount, or percent usage amount of any18
material, product, or good purchased by the participating eye care19
provider; or 20
(c) The brand, source, manufacturer, or supplier of a covered21
service or covered material utilized by the participating eye care22
provider. 23
(4) For the avoidance of doubt, this section does not prohibit24
advertising, provided that such advertising is (a) not false, misleading,25
or deceptive or (b) readily subject to verification.26
Sec. 10. An insurer or vision benefit manager shall not use27
extrapolation to complete an audit of a participating eye care provider.28
Any additional payment due to a participating eye care provider or any29
refund due to the insurer or vision benefit manager shall not be based on30
an extrapolation, but shall be based on the actual overpayment or31
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underpayment, as determined after an investigation by the insurer or1
vision benefit manager, and after the participating eye care provider has2
been afforded, and has exhausted, all opportunities to appeal the3
insurer's or vision benefit manager's findings, as set forth in the4
provider manual or policy document or applicable law.5
Sec. 11. (1) The requirements of the Vision Benefit Plan Act are in6
addition to, and do not limit, any other requirement applicable to an7
insurer under state law. In the event of a conflict between the act and8
another provision of state law applicable to insurers, the provision that9
affords greater protection to eye care providers or plan enrollees shall10
control. 11
(2) Notwithstanding any other provision of state law, including any12
law that purports to be the sole body of law governing the insurer, an13
insurer shall comply with the Vision Benefit Plan Act, to the extent not14
preempted by federal law. 15
Sec. 12. The director may adopt and promulgate rules and16
regulations to carry out the Vision Benefit Plan Act.17
Sec. 13. (1) Except as provided in subsection (2) of this section,18
the director shall enforce the Vision Benefit Plan Act, and any violation19
of the act or any rule and regulation adopted and promulgated pursuant to20
the act shall be an unfair trade practice in the business of insurance21
subject to the Unfair Insurance Trade Practices Act.22
(2) The Attorney General shall enforce any violations of the Vision23
Benefit Plan Act that are considered to be deceptive trade practices24
subject to penalty under the Uniform Deceptive Trade Practices Act.25
(3) The director shall provide a mechanism for aggrieved26
individuals, whether actively or formerly enrolled with a particular27
vision benefit plan, to submit complaints to the director for review,28
investigation, and, as appropriate, discipline under applicable law.29
(4) The penalties and remedies provided in this section for a30
violation of the Vision Benefit Plan Act shall be in addition to any31
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other penalties and remedies available under state law and shall not1
waive, limit, or otherwise affect the applicability of any other law2
providing for civil or criminal penalties or remedies for unfair,3
deceptive, or unlawful business practices. 4
Sec. 14. The Vision Benefit Plan Act shall apply to insurer or5
vision benefit manager policies, contracts, agreements, and plans6
delivered, issued for delivery, continued, or renewed in this state on or7
after the operative date of this act. 8
Sec. 15. This act becomes operative on July 1, 2026.9
Sec. 16. If any section in this act or any part of any section is10
declared invalid or unconstitutional, the declaration shall not affect11
the validity or constitutionality of the remaining portions.12
Sec. 17. Since an emergency exists, this act takes effect when13
passed and approved according to law. 14
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