An Act To Protect Vision Care Patients and Providers
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §2769 is enacted to read:
§ 2769. Vision care coverage
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Contractual discount" means a percentage or other reduction from a provider's usual and customary rate for a covered service or covered material required under a participating provider agreement.
B. "Covered material" means a material for which reimbursement from an insurer, limited benefit health insurance plan, limited benefit coverage plan or vision care plan is provided to a vision care provider by an enrollee's plan contract or for which reimbursement would be available but for the application of an enrollee's contractual obligations for deductibles, copayments or coinsurance.
C. "Covered service" means a service for which reimbursement from an insurer, limited benefit health insurance plan, limited benefit coverage plan or vision care plan is provided to a vision care provider by an enrollee's plan contract or for which reimbursement would be available but for the application of an enrollee's contractual obligations for deductibles, copayments or coinsurance.
D. "Insurer" means every person engaged as principal and as indemnitor, surety or contractor in the business of entering into a contract of health insurance, including those health insurance contracts described in chapters 9, 33, 35 and 56-A.
E. "Limited benefit coverage" means coverage limited to only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefits, including coverage limited to only vision care.
F. "Limited benefit health insurance plan" means a health insurance plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefits, including a plan that covers only vision care.
G. "Material" means ophthalmic devices, including but not limited to lenses, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens mounting apparatuses, prisms, lens treatments and coating, contact lenses and prosthetic devices to correct, relieve or treat defects or abnormal conditions of the human eye or its adnexa.
H. "Services" means the professional work performed by a vision care provider.
I. "Vision care plan" means insurance underwritten to provide coverage for eye care, including entities, products or policies that create, promote, sell, provide, advertise or administer integrated or stand-alone vision benefit plans or vision care insurance policies or contracts that provide vision benefits to an enrollee pertaining to the provisions of a covered service or covered material. "Vision care plan" includes a limited benefit health insurance plan and limited benefit coverage plan that provides coverage for eye care.
J. "Vision care provider" means a licensed doctor of optometry practicing under the authority of Title 32, chapter 34-A or a licensed osteopathic or medical doctor practicing under the authority of Title 32, chapter 36 or 48 who has also completed a residency in ophthalmology.
2. Noncovered services and materials provisions. An agreement between an insurer or vision care plan and a vision care provider may not seek to or require a vision care provider to provide services or materials at a fee limited or set by the insurer or vision care plan unless the services or materials are reimbursed as a covered service or a covered material under the agreement.
3. Prohibition on laboratory or supplier requirements. An agreement between an insurer or vision care plan and a vision care provider may not restrict or limit, directly or indirectly, the vision care provider's choice of sources and suppliers of services or materials or use of optical laboratories provided by the vision care provider to an enrollee in a vision care plan.
4. Notification requirements for contract changes. An insurer or vision care plan may not change any term, contractual discount or reimbursement rate contained in an agreement with a vision care provider without a signed written acknowledgment from the vision care provider at least 60 days before the change is implemented.
5. Credentialling. An agreement between an insurer or vision care plan and a vision care provider may not require that a vision care provider participate with or be credentialled by any specific limited benefit health insurance plan, limited benefit coverage plan or vision care plan as a condition of joining an insurer's provider network.
6. Contract length. A vision care plan agreement between an insurer and a vision care provider may not be longer than 2 years from the date the agreement is first signed.
7. Enforcement. The following provisions apply.
A. A person adversely affected by a violation of this section may bring an action in the Superior Court of the county in which the person resides or has the person's principal place of business, or may be brought in the Superior Court of Kennebec County. The Superior Court may issue temporary or permanent injunctions to restrain and prevent violations of this section and may make such other orders or judgments as may be necessary to restore to a person who has suffered an ascertainable loss by reason of the use or employment of an act in violation of this section, including recovery of monetary damages of no more than $1,000 for each day found to be in violation. A person who violates the terms of an injunction issued under this section shall forfeit and pay to the State a civil penalty of not more than $10,000 for each violation. Upon prevailing in an action under this section, when an injunction is denied, the court may order the defendant to pay the attorney's fees and costs of the prevailing party.
B. The superintendent or the Attorney General may also seek an injunction against an insurer or vision care plan in a court of competent jurisdiction with respect to a violation of this section. An action brought under this paragraph must be brought in accordance with the procedures for an injunction under Title 5, chapter 10.
8. Rules. The bureau shall adopt any rules necessary for the administration of this section. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
9. Application. The requirements of this section apply to all vision care plan policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after the effective date of this section. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
SUMMARY
This bill establishes standards relating to agreements between an insurer and a vision care provider related to insurance coverage for vision care.