SB0764eng 103RD GENERAL ASSEMBLY

SB0764 Engrossed LRB103 03219 BMS 48225 b

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 1. Short title. This Act may be cited as the Vision Care Plan Regulation Act.

Section 5. Definitions. As used in this Act:

"Covered materials" means materials for which reimbursement from the vision care plan is provided to an eye care provider by an enrollee's plan contract or for which a reimbursement would be available but for the application of the enrollee's contractual limitation of deductibles, copayments, or coinsurance. "Covered materials" includes lens treatment or coatings added to a spectacle lens if the base spectacle lens is a covered material.

"Covered services" means services for which reimbursement from the vision care plan is provided to an eye care provider by an enrollee's plan contract or for which a reimbursement would be available but for the application of the enrollee's contractual plan limitation of deductibles, copayments, or coinsurance regardless of how the benefits are listed in an enrollee's benefit plan's definition of benefits.

"Enrollee" means any individual enrolled in a vision care plan provided by a group, employer, or other entity that purchases or supplies coverage for a vision care plan.

"Eye care provider" means a doctor of optometry licensed pursuant to the Illinois Optometric Practice Act of 1987 or a physician licensed to practice medicine in all of its branches pursuant to the Medical Practice Act of 1987.

"Materials" means ophthalmic devices, including, but not limited to:

(i) lenses, devices containing lenses, ophthalmic frames, and other lens mounting apparatus, prisms, lens treatments, and coatings;

(ii) contact lenses and prosthetic devices that correct, relieve, or treat defects or abnormal conditions of the human eye or adnexa; and

(iii) any devices that deliver medication or other therapeutic treatment to the human eye or adnexa.

"Services" means the professional work performed by an eye care provider.

"Subcontractor" means any company, group, or third-party entity, including agents, servants, partially-owned or wholly-owned subsidiaries and controlled organizations, that the vision care plan contracts with to supply services or materials for an eye care provider or enrollee to fulfill the benefit plan of a vision care plan.

"Vision care organization" means an entity formed under the laws of this State or another state that issues a vision care plan.

"Vision care plan" means a plan that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone plan that provides coverage for covered services and covered materials.

Section 10. Noncovered services.

(a) No vision care organization that issues, delivers, amends, or renews a vision care plan on or after the effective date of this Act shall issue a contract that requires an eye care provider, as a condition of participation in the vision care plan, to provide services or materials to an enrollee at a fee set by the vision care plan unless the services or materials are covered services or covered materials under the vision care plan. De minimis reimbursements shall not qualify a service or material as a covered service or a covered material under this Act.

(b) An eye care provider who chooses not to accept as payment an amount set by a vision care plan for services or materials that are not covered services or covered materials shall post, in a conspicuous place, a notice stating the following: "IMPORTANT: This eye care provider does not accept the fee schedule set by your insurer for vision care services and vision care materials that are not covered benefits under your plan and instead charges his or her normal fee for those services and materials. This eye care provider will provide you with an estimated cost for each noncovered service or noncovered material upon your request."

Section 15. Fees for covered services and covered materials. Fees paid under a vision care plan for covered services and covered materials, regardless of the supplier or optical lab used to obtain materials, shall be reasonable and shall be clearly listed on a fee schedule that has been provided to the eye care provider before entering into a contract with the vision care organization. Fees paid for materials supplied by a non-network lab are not required to be identical to fees paid for materials ordered through a network lab, but non-network lab fees shall be reasonable.

Section 20. Misrepresentation.

(a) A vision care organization and its officers, directors, agents, and employees are subject to the provisions of Sections 149 and 154.6 of the Illinois Insurance Code.

(b) Incorporation by reference in this Act to specific laws of this State shall not be construed to exempt a vision care organization or vision care plan from otherwise applicable laws that are not specifically referenced in this Act.

Section 25. Subcontractors. The provisions of this Act apply to any subcontractors used by a vision care organization to supply materials or services to an eye care provider or an enrollee under a vision care plan.

Section 30. Suppliers; optical labs.

(a) A vision care organization may not restrict or limit an eye care provider's choice of suppliers of services, covered materials, or the use of an optical lab.

(b) A vision care organization may not require an eye care provider or patient to order or purchase covered materials, including, but not limited to, ophthalmic lenses, from any source owned by, controlled by, or in a common ownership scheme with the entity that issued the vision care plan.

(c) At the request of an enrollee, an eye care provider recommending an out-of-network source or supplier of vision care materials to an enrollee shall provide written notice to the enrollee stating:

(1) that the source or supplier is an out-of-network laboratory or supplier of vision care materials; and

(2) any business interest that the eye care provider has in the out-of-network source or supplier recommended to the enrollee.

(d) An eye care provider is required to offer an enrollee in-network sources or suppliers of vision care materials at the enrollee's request.

Section 35. Modification of plan.

(a) The terms, fees, discounts, or reimbursement rates in a vision care plan may not be changed during the term of the contract unless mutually agreed to in writing by the eye care provider and the vision care organization that issued the vision care plan. However, a change proposed to a vision care plan by the vision care organization shall become effective if the eye care provider fails to respond to the vision care organization within 60 days after receipt of notice of the proposed changes.

(b) The terms of a vision care plan contract that is amended, delivered, issued, or renewed after the effective date of this Act shall comply with the provisions of this Act.

Section 40. Prohibitions; medical plan preconditions.

(a) No vision care organization that issues, delivers, amends, or renews a vision care plan on or after the effective date of this Act shall issue a vision care plan contract that requires:

(1) an eye care provider to contract with a plan that offers supplemental or specialty health care services as a condition of contracting with a plan that offers basic health services; or

(2) an eye care provider to contract with a vision care plan as a condition to participation in a medical plan or in-network.

(b) A vision care plan may enter into an agreement with a health care plan to deliver routine vision care services that are covered under the enrollee's plan.

(c) A vision care plan may act as a network regarding routine vision care services offered by a health care plan.

Section 900. The Consumer Fraud and Deceptive Business Practices Act is amended by adding Section 2BBBB as follows:

(815 ILCS 505/2BBBB new)

Sec. 2BBBB. Violations of the Vision Care Plan Regulation Act. Any person who violates the Vision Care Plan Regulation Act commits an unlawful practice within the meaning of this Act.

Section 999. Effective date. This Act takes effect upon becoming law.