A. All health benefit plans offered by the Office of Management and Enterprise Services which provide for services for vision care or medical diagnosis and treatment for the eye shall allow optometrists to be providers of those services. All such health benefit plans shall also require equal payment for the same services provided by an optometrist if the services are within the scope of practice of optometry.
B. With respect to optometric services, any health benefit plan offered by the Office which uses a gatekeeper or equivalent for referrals for services for vision care or for medical diagnosis and treatment of the eye shall require such covered services be provided on a referral basis within the medical group or network at the request of an enrollee who has a condition requiring vision care or medical diagnosis and treatment of the eye if:
1. A referral is necessitated in the judgment of the primary care physician; and
2. Treatment for the condition falls within the licensed scope of practice of an optometrist.
C. All health benefit plans offered by the Office shall have a defined set of standards and procedures for selecting providers, including specialists, to serve enrollees. The standards and procedures shall be drafted in such a manner that they are applicable to all categories of providers and shall be utilized by the health maintenance organization in a manner that is without bias for or discrimination against a particular category or categories of providers.
D. No health benefit plan specified by this section shall require a provider to have hospital privileges if hospital privileges are not usual and customary for the services the provider provides.
E. Nothing in this section shall be construed to:
1. Prohibit a health benefit plan offered by the Office which provides for services for vision care or medical diagnosis and treatment for the eye from determining the adequacy of the size of its network;
2. Prohibit an optometrist from agreeing to a fee schedule;
3. Limit, expand, or otherwise affect the scope of practice of optometry; or
4. Alter, repeal, modify or affect the laws of this state except where such laws are in conflict or are inconsistent with the express provisions of this section.
F. Existing health benefit plans offered by the Office shall comply with the requirements of this section upon issuance or renewal on or after the effective date of this act.
Added by Laws 2000, c. 54, § 4, eff. Nov. 1, 2000. Amended by Laws 2012, c. 304, § 971.