Sponsored by:
Senator NICHOLAS P. SCUTARI
District 22 (Middlesex, Somerset and Union)
Senator GERALD CARDINALE
District 39 (Bergen and Passaic)
SYNOPSIS
Prohibits health insurance carriers from requiring optometrists to become providers with vision care plans as condition of becoming providers in carriers' panel of providers; prohibits certain practices under vision care provider contracts.
CURRENT VERSION OF TEXT
As reported by the Senate Commerce Committee on December 4, 2017, with amendments.
An Act concerning optometrists and vision care plans and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. A carrier shall not require an optometrist to participate in a vision care plan as a condition for entering into a contract with that carrier for the provision of medically necessary physician services within the scope of practice of an optometrist 1[when those services are provided as a health benefit for covered persons]1.
b. 1[For purposes of this section, "vision care plan" means an organization with which a carrier subcontracts to provide or administer supplemental vision or medically necessary physician services within the scope of practice of an optometrist, or both, to covered persons on behalf of the carrier.
c.]1 Nothing in this section shall be construed to prevent a carrier from entering into a contract with a vision care plan.
12. a. No contract between a carrier or a vision care plan and a vision care provider may seek to or require that a vision care provider provide services or materials at a fee limited or set by the carrier or vision care plan unless the services or materials are reimbursed as covered services or covered materials under the contract.
b. A vision care provider shall not charge more for services and materials that are noncovered services or noncovered materials to an enrollee of a vision care plan or carrier than the provider's usual and customary rate for those services and materials.1
13. No contract between a carrier or vision care plan and a vision care provider shall restrict or limit, either directly or indirectly, the vision care provider's choice of sources and suppliers of services or materials or use of optical labs provided by the vision care provider to an enrollee.1
14. As used in this act:
"Contractual discount" means a reduction from a vision care provider's usual and customary rate for covered services and materials required under a participating provider agreement.
"Covered materials" means materials for which reimbursement from the carrier or vision care plan is provided to a vision care provider by a covered person's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance.
"Covered services" means services for which reimbursement from the carrier or vision care plan is provided to a vision 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 limitations of deductibles, copayments, or coinsurance.
"Materials" means ophthalmic devices including but not limited to lenses, devices containing lenses, ophthalmic frames and other lens mounting apparatus, prisms, lens treatments and coatings contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.
"Services" means the professional work performed by a vision care provider.
"Vision care plan" means an entity that creates, promotes, sells, provides, advertises or administers, an integrated or stand-alone vision benefit plan, or a vision care insurance policy or contract which provides vision or medically necessary benefits to an enrollee pertaining to the provision of covered services or covered materials.
"Vision care provider" means a licensed doctor of optometry practicing under the authority of R.S.45:12-1 et seq. or a licensed medical or osteopathic doctor practicing under the authority of R.S.45:9-1 et seq. that has also completed a residency in ophthalmology.1
1[2.] 5.1 This act shall take effect on the 120th day next following enactment.