A. Any health benefit plan which offers services for vision care or medical diagnosis and treatment for the eye shall allow optometrists to be providers of those services.

B. With respect to optometric services, any health benefit plan 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. Each health benefit plan 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 benefit plan in a manner that is without bias for or discrimination against a particular category or categories of providers.

D. No health benefit plan shall require a provider to have hospital privileges if hospital privileges are not usual and customary for the services the provider provides.

E. Health benefit plans shall provide that optometrists be equally compensated for covered services and procedures provided to an insured on the basis of charges prevailing in the same geographical area or in similar-sized communities for similar services and procedures as provided in the Health Care Freedom of Choice Act, if the services are within the scope of practice of optometry.

F. Nothing in this section shall be construed to:

1. Prohibit a health benefit plan which offers 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.

G. Existing health benefit plans shall comply with the requirements of this section upon issuance or renewal on or after the effective date of this act.

H. As used in this section, "health benefit plan" means individual or group hospital or medical insurance coverage, a not-for-profit hospital or medical service or indemnity plan, a prepaid health plan, a health maintenance organization plan, a preferred provider organization plan, the State and Education Employees Group Health Insurance Plan, any program funded under Title XIX of the Social Security Act or such other publicly funded program, and coverage provided by a Multiple Employer Welfare Arrangement (MEWA) or employee self-insured plan except as exempt under federal ERISA provisions.

Added by Laws 2000, c. 54, § 1, eff. Nov. 1, 2000.