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1 1 Section 1. NEW SECTION. 514I.1 DEFINITIONS.
1 2 As used in this chapter, unless the context otherwise
1 3 requires:
1 4 1. "Carrier" means a person who provides individual or
1 5 group health insurance or health benefits in this state.
1 6 "Carrier" includes an insurance company, a group hospital or
1 7 medical services corporation, a fraternal benefit society, a
1 8 health maintenance organization, an organized delivery system,
1 9 and any other person providing a plan of health insurance or
1 10 health benefits subject to state regulation by the
1 11 commissioner of insurance.
1 12 2. "Class of primary eye care provider" means either
1 13 ophthalmologists or optometrists.
1 14 3. "Covered services" means health care services,
1 15 including, but not limited to, medical and vision care
1 16 services, procedures, and materials for which a carrier is
1 17 obligated to pay or which a carrier is obligated to provide to
1 18 an enrollee under a health benefit plan.
1 19 4. "Enrollee" means an individual or a dependent of the
1 20 individual who is enrolled in a health benefit plan on whose
1 21 behalf the carrier is obligated to provide covered services.
1 22 5. "Health benefit plan" means any public or private
1 23 health plan, program, policy, or agreement implemented in this
1 24 state and issued by a carrier which provides medical or vision
1 25 care benefits to enrollees, including, but not limited to,
1 26 plan which provide workers' compensation benefits.
1 27 6. "Opthalmologist" means a physician licensed pursuant to
1 28 chapter 148 or 150A, whose practice is limited to medical and
1 29 surgical care of the eye and visual system, and to routine
1 30 vision care.
1 31 7. "Optometrist" means a person licensed pursuant to
1 32 chapter 154 to practice optometry who is therapeutically
1 33 certified.
1 34 8. "Preferred provider" means a primary care provider or
1 35 group of primary care providers who have contracted with a
2 1 carrier to provide specified covered services.
2 2 9. "Primary care provider" means any physician licensed
2 3 pursuant to chapter 148 or 150A, a hospital licensed under
2 4 chapter 135B, or a person as defined in chapter 4 licensed or
2 5 otherwise authorized in this state to furnish primary health
2 6 care services.
2 7 10. "Primary care provider system" means a system of
2 8 administration used by a health benefit plan in which a
2 9 primary care provider furnishes primary health care services,
2 10 including diagnosis, treatment, coordination of care, and
2 11 referral for specialty care for persons covered by a health
2 12 benefit plan.
2 13 11. "Primary eye care" means those health care services,
2 14 procedures, and materials relating to medical care of the eye
2 15 and related structures, and vision care services, procedures,
2 16 and materials for which a carrier is obligated to pay or which
2 17 a carrier is obligated to provide to enrollees under a health
2 18 benefit plan.
2 19 12. "Primary eye care provider" means an ophthalmologist
2 20 or optometrist.
2 21 13. "Primary health care services" means services rendered
2 22 or products sold by a primary care provider within the scope
2 23 of the primary care provider's license.
2 24 Sec. 2. NEW SECTION. 514I.2 HEALTH BENEFIT PLAN –
2 25 REQUIREMENTS.
2 26 1. A health benefit plan shall comply with all of the
2 27 following:
2 28 a. Assure enrollees direct access to primary eye care
2 29 providers without prior referral for primary eye care by a
2 30 primary care provider.
2 31 b. Allow an enrollee to seek primary eye care from a
2 32 primary eye care provider who is not included in the preferred
2 33 provider list of the health benefit plan. However, the health
2 34 benefit plan may require a different copayment amount for
2 35 primary eye care provided by a primary eye care provider not
3 1 included in the preferred provider list as established by rule
3 2 issued by the commissioner.
3 3 c. Assure that all primary eye care providers under the
3 4 health benefit plan are included in any publicly accessible
3 5 list of primary care provider participants in the plan.
3 6 d. Assure that an adequate number of primary eye care
3 7 providers are included in the health benefit plan, in order to
3 8 guarantee reasonable accessibility, timelines of care,
3 9 convenience, and continuity of care to enrollees.
3 10 e. Allow a primary eye care provider, regardless of the
3 11 class of primary eye care provider, to provide covered primary
3 12 eye care to enrollees.
3 13 2. A health benefit plan shall not do any of the
3 14 following:
3 15 a. Penalize or discriminate against an enrollee who seeks
3 16 primary eye care directly from a primary eye care provider
3 17 included in the health benefit plan.
3 18 b. Establish fees or reimbursement for the same or similar
3 19 primary health care services in a manner which discriminates
3 20 against an individual primary eye care provider or a class of
3 21 primary eye care providers.
3 22 c. Promote or recommend any class of primary care
3 23 providers to an enrollee.
3 24 d. Require a primary eye care provider to hold hospital
3 25 privileges.
3 26 e. Impose any other condition or restriction upon a
3 27 primary eye care provider which would exclude a class of
3 28 primary eye care providers from participation in the health
3 29 benefit plan.
3 30 Sec. 3. NEW SECTION. 514I.3 EXCEPTIONS – RELIEF.
3 31 1. This chapter shall not be interpreted to preclude an
3 32 enrollee from receiving emergency medical eye care or to
3 33 preclude an enrollee from receiving treatment for primary
3 34 health care services from the enrollee's personal physician in
3 35 accordance with the terms of the health benefit plan.
4 1 2. A person adversely affected by a violation of this
4 2 chapter may commence an action to enjoin the carrier from
4 3 continuing the violation. Additionally, if the person
4 4 commencing the action prevails, the court may grant the
4 5 prevailing party damages of not less than one thousand
4 6 dollars, attorney fees, and court costs.
4 7 EXPLANATION
4 8 This bill provides for direct patient access through health
4 9 benefit plans to primary eye care providers, defined in the
4 10 bill as ophthalmologists and optometrists. The bill specifies
4 11 requirements of health benefit plans, provides for exceptions,
4 12 and provides for injunctive relief and damages for violation
4 13 of the provisions of the bill.
4 14 LSB 4379SC 76
4 15 pf/cf
Text: SSB02344 Text: SSB02346 Text: SSB02300 - SSB02399 Text: SSB Index Bills and Amendments: General Index Bill History: General Index
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