CODE OF VIRGINIA

PAYMENT FOR SERVICES BY OPTOMETRISTS AND OPHTHALMOLOGISTS (§ 38.2-3407.19)

A. As used in this section, unless the context requires a different
meaning:”Covered materials” means lenses, devices containing lenses,
prisms, lens treatments and coatings, contact lenses, and devices to correct,
relieve, or treat defects or abnormal conditions of the human eye and its adnexa
for which benefits under a policy, contract, or evidence of coverage are payable
by a vision care plan carrier, including materials paid by the insureds,
subscribers, or enrollees because the annual or periodic payment maximum
established by the vision care plan has been met.”Covered services”
means the health care services for which benefits under a policy, contract, or
evidence of coverage are payable by a vision care plan carrier, including
services paid by the insureds, subscribers, or enrollees because the annual or
periodic payment maximum established by the vision care plan has been
met.”Enrollee” means any person entitled to health care services
under a vision care plan.”Optometric services plan” has the same
meaning ascribed thereto in § 38.2-4501.”Participating provider
agreement” means a contract or agreement between an optometrist or
ophthalmologist and a vision care plan carrier in which the optometrist or
ophthalmologist has agreed to provide vision-related health care services to
enrollees and to hold those enrollees harmless from payment with an expectation
of receiving payment, other than copayments or deductibles, directly or
indirectly from a vision care plan.”Vision care plan” means (i) an
individual or group accident and sickness insurance policy providing hospital,
medical, and surgical or major medical coverage on an expense-incurred basis;
(ii) an individual or group accident and sickness subscription contract; (iii)
an optometric services plan; (iv) a health care plan provided by a health
maintenance organization; or (v) an integrated or stand-alone vision benefit
plan or a vision care insurance policy or contract that provides vision benefits
to an enrollee pertaining to the provision of covered services or covered
materials, under which policy, contract, or plan an enrollee is eligible to
receive a benefit for covered services or covered materials.”Vision care
plan carrier” means (i) an insurer proposing to issue individual or group
accident and sickness insurance policies providing hospital, medical, and
surgical or major medical coverage on an expense-incurred basis; (ii) a nonstock
corporation providing individual or group accident and sickness subscription
contracts; (iii) a nonstock corporation offering an optometric services plan;
(iv) a health maintenance organization providing a health care plan; and (v) an
entity that creates, promotes, sells, provides, advertises, or administers (a)
an integrated or stand-alone vision benefit plan or (b) a vision care insurance
policy or contract that provides vision benefits to an enrollee pertaining to
the provision of covered services or covered materials.

B. No participating provider agreement shall establish the fee or rate that the
optometrist or ophthalmologist is required to accept for the provision of health
care materials or services, or require that an optometrist or ophthalmologist
accept the reimbursement paid as payment in full, unless the health care
materials and services are covered materials or covered services under the
applicable vision care plan.

C. Reimbursement paid by the vision care plan carrier for covered services and
covered materials shall be reasonable and shall not provide nominal
reimbursement in order to claim that services and materials are covered services
or covered materials under the applicable vision care plan. For the purposes of
this subsection, “reasonable” means the negotiated fee or rate that
is set forth in the participating provider agreement and is acceptable to the
provider.

D. No vision care plan shall require an optometrist or ophthalmologist to use a
particular optical laboratory, manufacturer of eyeglass frames or contact
lenses, or third-party supplier as a condition of participation in a vision care
plan.

E. Any changes to a participating provider agreement proposed by the vision care
plan carrier shall be submitted in writing to the optometrist or ophthalmologist
at least 30 days prior to the effective date of such proposed changes.

F. This section shall apply with respect to any participating provider agreement
that is entered into, amended, extended, or renewed on or after January 1, 2016.

G. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

H. The provisions of subsections B through G, as related to covered materials
only, shall be applicable to licensed opticians practicing in the Commonwealth.

HISTORY: 2015, c. 723.