Patient Access to Eye Care

  1. Law
  2. Georgia Code
  3. Insurance
  4. Insurance Generally
  5. General Provisions
  6. Patient Access to Eye Care

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  1. This Code section shall be known and may be cited as the "Patient Access to Eye Care Act."
  2. As used in this Code section, the term:
    1. "Covered person" means an individual enrolled in a health benefit plan or an eligible dependent thereof.
    2. "Covered services" means those health care services which a health care insurer is obligated to pay for or provide to a covered person under a health benefit plan.
    3. "Eye care" means those health care services and materials related to the care of the eye and related structures and vision care services which a health care insurer is obligated to pay for or provide to covered persons under the health benefit plan.
    4. "Health benefit plan" means any public or private health plan, program, policy, or agreement implemented in this state which provides health benefits to covered persons, including but not limited to payment and reimbursement for health care services.
    5. "Health care insurer" means an entity, including but not limited to insurance companies, health care corporations, health maintenance organizations, and preferred provider organizations, authorized by the state to offer or provide health benefit plans, programs, policies, subscriber contracts, or any other agreements of a similar nature which compensate or indemnify health care providers for furnishing health care services.
  3. A health care insurer providing a health benefit plan which includes eye care benefits shall:
    1. Not set professional fees or reimbursement for the same eye care services as defined by established current procedural terminology codes in a manner that discriminates against an individual eye care provider or a class of eye care providers;
    2. Not preclude a covered person who seeks eye care from obtaining such service directly from a provider on the health benefit plan provider panel who is licensed to provide eye care;
    3. Not promote or recommend any class of providers to the detriment of any other class of providers for the same eye care service;
    4. Ensure that all eye care providers on a health benefit plan provider panel are included on any publicly accessible list of participating providers for the plan;
    5. Allow each eye care provider on a health benefit plan provider panel, without discrimination between classes of eye care providers, to furnish covered eye care services to covered persons to the extent permitted by such provider's licensure;
    6. Not require any eye care provider to hold hospital privileges or impose any other condition or restriction for initial admittance to a provider panel not necessary for the delivery of eye care upon such providers which would have the effect of excluding an individual eye care provider or class of eye care providers from participation on the health benefit plan; and
    7. Include optometrists and ophthalmologists on the health benefit plan provider panel in a manner that ensures plan enrollees timely access and geographic access.
  4. Nothing in this Code section shall preclude a covered person from receiving eye care or other covered services from the covered person's personal physician in accordance with the terms of the health benefit plan.
  5. A person adversely affected by a violation of this Code section by a health care insurer may bring an action in a court of competent jurisdiction for injunctive relief against such insurer and, upon prevailing, in addition to any injunctive relief that may be granted, shall recover from such insurer damages of not more than $100.00 and attorney's fees and costs.
  6. Nothing in this Code section requires a health benefit plan to include eye care benefits.
  7. The Commissioner is authorized to enforce this Code section and, in doing so, to exercise the powers granted to the Commissioner by Code Section 33-2-24 and any other provisions of this title.

(Code 1981, §33-24-59.12, enacted by Ga. L. 2005, p. 692, § 2/SB 81; Ga. L. 2017, p. 164, § 34/HB 127.)

Law reviews.

- For annual survey on insurance law, see 66 Mercer L. Rev. 93 (2014).

JUDICIAL DECISIONS

Independent participating provider agreement violated section.

- Georgia Court of Appeals correctly interpreted the Patient Access to Eye Care Act, O.C.G.A. § 33-24-59.12(c)(2), and determined that an insurer's independent participating provider (IPP) agreements violated that section as the IPP prohibited providers from providing certain eye care, in particular the preparation of eyeglasses, directly to the insureds, therefore, the IPP agreement violated paragraph (c)(2). Spectera, Inc. v. Wilson, 294 Ga. 23, 749 S.E.2d 704 (2013).

Georgia Court of Appeals was incorrect in finding that an insurer's independent participating provider (IPP) agreement violated the Patient Access to Eye Care Act, O.C.G.A. § 33-24-59.12(c)(5), because the IPP agreement did not in any way create the type of impermissible discrimination between classes of licensed eye care providers contemplated by paragraph (c)(5). Spectera, Inc. v. Wilson, 294 Ga. 23, 749 S.E.2d 704 (2013).


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