ENGROSSED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 167
(By Senators Bowman, Kessler, McKenzie, Edgell, Dittmar,
Dawson, Minard and Plymale)
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[Originating in the Committee on Banking and Insurance;
reported February 28, 2000.]
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A BILL to amend chapter thirty-three of the code of West
Virginia, one thousand nine hundred thirty-one, as amended,
by adding thereto a new article, designated article twenty-
five-e, relating to creating the patient's eye care act;
providing definitions; limitations on coverage; requiring
certain disclosures; and other rights.
Be it enacted by the Legislature of West Virginia:
That chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article twenty-five-e,
to read as follows:
ARTICLE 25E. PATIENTS' EYE CARE ACT.
§33-25E-1.Short title
This article may be referred to as the patients' eye care
act.
§33-25E-2. Definitions.
For the purposes of this article:
(a)"Covered person" means an individual enrolled in a
health benefit plan or an eligible dependent of that person.
(b)"Eye care provider" means an optometrist or
ophthalmologist licensed by the state of West Virginia.
(c)"Eye care benefits" means coverage for the diagnosis,
treatment and management of eye disease and injury.
(d)"Health benefit policy" means any individual or group
plan, policy or contract providing medical, hospital or surgical
coverage issued, delivered, issued for delivery or renewed in
this state by an insurer, after the first day of January, two
thousand one. It does not include credit accident and sickness,
long-term care, medicare supplement, champus supplement,
disability or limited benefits policies.
(e)"Insurer" means any health care corporation, health maintenance organization, accident and sickness insurer,
nonprofit hospital service corporation, nonprofit medical service
corporation or similar entity.
(f)"Vision care benefits" means benefits for the
refraction of the eyes and other optical benefits.
§33-25E-3. Limitations on conditions of coverage.
(a)Health benefits policies may not require that an
optometrist hold hospital staff privileges.
(b)When any health benefits policy provides for the
payment of eye care benefits or vision care benefits, such policy
shall be construed to include payment to all eye care providers
who provide benefits within the scope of their providers'
licenses.
(c)Any limitation or condition placed upon services,
diagnosis or treatment by or payment to a particular type of
licensed provider shall apply equally to all licensed providers
without unfair discrimination as to the usual and customary
treatment procedures of an eye care provider.
(d)Any health benefits policy that includes eye care
benefits, including a diabetic retinal examination, shall provide
each covered person diagnosed with diabetes direct access to an
eye care provider of their choice from the insurer's panel of providers independent of, and without referral from, any other
provider or entity for one annual diabetic retinal examination.
The eye care provider shall provide copies of the results of the
examination to the covered person's primary care physician. No
other services shall be provided to the covered person by the eye
care provider without the prior authorization of the insurer or
of its designee. This benefit shall be subject to all
coinsurance, deductibles, copayments and other policy
requirements. When the diabetic retinal examination reveals the
beginning stages of an abnormal condition, access to future
examinations shall be subject to prior authorization from a
primary care physician.
(e)Any health benefits policy that includes eye care
benefits or vision care benefits shall include both optometrists
and ophthalmologists.
(f)This article may not be construed to require any health
benefits policy to cover any specific health care service.
(g)This article may not be construed to require a health
benefit plan or an insurer to include on the insurer's panel of
providers all providers willing to meet the terms and conditions
of participation as a plan provider.
§33-25E-4. Required disclosure.
Every health benefits policy that is issued, delivered,
issued for redelivery or renewed in this state on or after the
first day of January, two thousand one, that provides for eye
care benefits, including a diabetic retinal examination, shall
disclose in writing, in clear and accurate language, to
enrollees, subscribers, providers and insureds that any covered
person diagnosed with diabetes has the right to direct access to
an eye care provider of their choice from the insurer's panel of
providers for an annual diabetic retinal examination.