(a) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not establish a fee that a vision care provider shall charge for services or materials that are not covered by a vision benefit plan or contract.
(b) A vision care provider shall not charge a fee for services or materials that is more than the vision care provider's normal rate for the services or materials if the services or materials are noncovered services or noncovered materials.
(c) (1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not require a vision care provider to apply a discount to an individual who is insured by the insurer with a participating vision care provider for noncovered services or noncovered materials.(2) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not avoid the restriction under subdivision (c)(1) of this section by providing minimal reimbursement for a service or materials to apply a discount.
(1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not require a vision care provider to apply a discount to an individual who is insured by the insurer with a participating vision care provider for noncovered services or noncovered materials.
(2) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not avoid the restriction under subdivision (c)(1) of this section by providing minimal reimbursement for a service or materials to apply a discount.
(d) A reimbursement paid by an insurer, vision benefit manager, vision care plan, or vision care discount plan to a vision care provider for covered services and covered materials shall not be:(1) Nominal or de minimis; or(2) Less than the current calendar year Medicare reimbursement rate for the covered service or covered materials provided to the enrollee.
(1) Nominal or de minimis; or
(2) Less than the current calendar year Medicare reimbursement rate for the covered service or covered materials provided to the enrollee.
(e) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not require that a vision care provider participate with or be credentialed by any specific vision care plan or vision care discount plan as a condition to join an insurer's provider panel.
(f) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not restrict or limit, directly or indirectly, the vision care provider's choice of optical labs or choice of sources and suppliers of services or materials provided by the vision care provider to an individual who is insured by the insurer.
(g) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall identify participating vision care providers in a neutral manner and shall not distinguish between participating vision care providers based on the following characteristics:(1) Discount or incentive offered by the vision care provider on services and materials that are not covered by the insurer or vision benefit manager, vision care plan, or vision care discount plan;(2) The dollar amount, volume amount, or percent usage amount of any material or good purchased by the vision care provider; or(3) The brand, source, manufacturer, or supplier of a covered service or covered product utilized by the vision care provider.
(1) Discount or incentive offered by the vision care provider on services and materials that are not covered by the insurer or vision benefit manager, vision care plan, or vision care discount plan;
(2) The dollar amount, volume amount, or percent usage amount of any material or good purchased by the vision care provider; or
(3) The brand, source, manufacturer, or supplier of a covered service or covered product utilized by the vision care provider.
(h) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not advertise that services and materials are covered with additional copay or coinsurance if the health benefit plan, vision benefit plan, or vision benefit discount plan does not reimburse the participating vision care provider for the services or materials in order to claim that services and materials are covered services and materials.
(i) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not steer enrollees to, or limit the enrollees' choice of, vision care provider for services or materials that are not covered services or not covered materials.
(j) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not incentivize, recommend, encourage, persuade, or attempt to persuade an enrollee to obtain covered services, noncovered services, covered materials, or noncovered materials:(1) At any particular participating vision care provider over another participating vision care provider;(2) At a retail establishment owned by, partially owned by, contracted with, or otherwise affiliated with the insurer, vision benefit manager, vision care plan, or vision care discount plan instead of a different vision care provider; or(3) At any internet or virtual provider or retailer owned by, partially owned by, contracted with, or otherwise affiliated with the vision plan instead of a different participating vision care provider.
(1) At any particular participating vision care provider over another participating vision care provider;
(2) At a retail establishment owned by, partially owned by, contracted with, or otherwise affiliated with the insurer, vision benefit manager, vision care plan, or vision care discount plan instead of a different vision care provider; or
(3) At any internet or virtual provider or retailer owned by, partially owned by, contracted with, or otherwise affiliated with the vision plan instead of a different participating vision care provider.
(k) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not reimburse a vision care provider a different amount for covered services or covered materials because of the vision care provider's choice of:(1) Optical laboratory;(2) Source of supplier of:(A) Contact lenses;(B) Ophthalmic lenses;(C) Ophthalmic glasses frames; or(D) Covered services, covered materials, noncovered services, or noncovered materials;(3) Equipment used for patient care;(4) Retail optical affiliation;(5) Vision support organization;(6) Group purchasing organization;(7) Doctor alliance;(8) Professional trade association membership;(9) Electronic health record software, electronic medical record software, or practice management software; or(10) Third-party claim filing service, billing service, or electronic data interchange clearinghouse company.
(1) Optical laboratory;
(2) Source of supplier of:(A) Contact lenses;(B) Ophthalmic lenses;(C) Ophthalmic glasses frames; or(D) Covered services, covered materials, noncovered services, or noncovered materials;
(A) Contact lenses;
(B) Ophthalmic lenses;
(C) Ophthalmic glasses frames; or
(D) Covered services, covered materials, noncovered services, or noncovered materials;
(3) Equipment used for patient care;
(4) Retail optical affiliation;
(5) Vision support organization;
(6) Group purchasing organization;
(7) Doctor alliance;
(8) Professional trade association membership;
(9) Electronic health record software, electronic medical record software, or practice management software; or
(10) Third-party claim filing service, billing service, or electronic data interchange clearinghouse company.
(l) The terms, discounts, and reimbursement rates in a participating contract between an insurer, vision benefit manager, vision care plan, or vision care discount plan with a vision care provider shall not be modified during the term of a participating contract absent written authorization from the vision care provider.
(m) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not require a vision care provider to accept a reimbursement payment in the form of a virtual credit card or any other payment method wherein a processing fee, administrative fee, percentage amount, or dollar amount is assessed to the vision care provider to receive a reimbursement payment.
(n) (1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not use extrapolation to complete an audit of a participating vision care provider.(2) An additional payment due to a participating vision care provider or a refund due to the insurer or vision benefit manager shall not be based on an extrapolation, but shall be based on the actual overpayment or underpayment, as determined after an investigation by the insurer, vision benefit manager, vision care plan, or vision care discount plan, and after the participating vision care provider has been afforded, and has exhausted, all opportunities to appeal the insurer, vision benefit manager, vision care plan, or vision care discount plan's findings, as stated in the provider manual or policy document, or applicable law.
(1) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not use extrapolation to complete an audit of a participating vision care provider.
(2) An additional payment due to a participating vision care provider or a refund due to the insurer or vision benefit manager shall not be based on an extrapolation, but shall be based on the actual overpayment or underpayment, as determined after an investigation by the insurer, vision benefit manager, vision care plan, or vision care discount plan, and after the participating vision care provider has been afforded, and has exhausted, all opportunities to appeal the insurer, vision benefit manager, vision care plan, or vision care discount plan's findings, as stated in the provider manual or policy document, or applicable law.
(o) (1) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not prohibit a vision care provider from accepting a cash payment option from the enrollee if the cash payment option is less costly to the enrollee than the total out-of-pocket cost of the service or material.(2) A vision care provider shall not be subject to an audit for offering a cash price option for services and materials.
(1) A participating provider agreement between an insurer, vision benefit manager, vision care plan, or vision care discount plan and a vision care provider shall not prohibit a vision care provider from accepting a cash payment option from the enrollee if the cash payment option is less costly to the enrollee than the total out-of-pocket cost of the service or material.
(2) A vision care provider shall not be subject to an audit for offering a cash price option for services and materials.
(p) An insurer, vision benefit manager, vision care plan, or vision care discount plan shall not withhold or recoup a contracted amount for a covered service or covered material provided to an enrollee if the enrollee is verified to be eligible by the vision care provider through customary verification methods of the insurer, vision benefit manager, vision care plan, or vision care discount plan to receive the covered service or covered material on the date of service.
(q) An optician licensed under the Ophthalmic Dispensing Act, § 17-89-101 et seq., is subject to:(1) Subsections (c) and (f) of this section; and(2) Subsection (b) of this section in regard to materials.
(1) Subsections (c) and (f) of this section; and
(2) Subsection (b) of this section in regard to materials.