§ 31A-22-648 — Vision insurance -- Contract provisions.

Utah § 31A-22-648

• Jurisdiction: Utah
• Title 31A: Insurance Code
• Ch. 31A-22: Contracts in Specific Lines
• Part 31A-22-6: Accident and Health Insurance

Text

(1) As used in this section:

(1)(a) "Covered individual" means an individual who has insurance coverage under a vision plan.
(1)(b) "Covered service" means a vision service that:
(1)(b)(i) is reimbursable under or would be reimbursable under an enrollee's vision plan, but for the application of at least one of the following contractual provisions:

(1)(b)(i)(A) a deductible;
(1)(b)(i)(B) a copayment;
(1)(b)(i)(C) coinsurance;
(1)(b)(i)(D) a waiting period;
(1)(b)(i)(E) an annual or lifetime maximum;
(1)(b)(i)(F) a frequency limitation; or
(1)(b)(i)(G) an alternative benefit payment; and
(1)(b)(ii) is not merely nominal, for the purpose of avoiding the requirements of this section.
(1)(c) "Optometrist" means an individual licensed under Title 58, Chapter 16a, Utah Optometry Practice Act.
(1)(d) "Vendor" means a person who provides ophthalmic goods to a vision service provider.
(1)(e) "Vision plan" means a health insurance policy or contract that provides vision coverage.
(1)(f) "Vision service" means:
(1)(f)(i) professional work performed by a vision service provider; or
(1)(f)(ii) an opthalmic medical device, such as lenses, opthalmic frames, contact lenses, or a prosthetic device that treats a condition of the human eye or the areas surrounding the human eye.
(1)(g) "Vision service provider" means:
(1)(g)(i) an optometrist; or
(1)(g)(ii) an individual who provides a vision service and is licensed under:

(1)(g)(ii)(A) Title 58, Chapter 67, Utah Medical Practice Act; or
(1)(g)(ii)(B) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.
(2) (2)(a) This section applies to:
(2)(a)(i) a vision plan that a person enters into or renews on or after January 1, 2019; and
(2)(a)(ii) an administrator providing third-party administration services or a provider network for a vision plan.
(2)(b) This section does not apply to a self-insured vision plan that is regulated by federal law.
(3) A contract between a vision plan and a vision service provider to provide a covered service may not:

(3)(a) except as provided in Subsection (4), require that a vision service provider provide a vision service to a covered individual at a fee set by, or a fee subject to the approval of, the vision plan unless the vision service is a covered service;
(3)(b) prohibit a vision service provider from offering or providing a vision service that is not a covered service to a covered individual at a fee determined by:
(3)(b)(i) the vision service provider; or
(3)(b)(ii) the vision service provider and the covered individual; or
(3)(c) require a vision service provider to use one or more specific vendors to replenish the vision service provider's inventory of spectacle lenses after the vision service provider dispenses the vision service provider's inventory to eligible members of the vision plan as a covered vision service.
(4) (4)(a) In accordance with Subsections (4)(b) and (c), a vision service provider may, in a contract with a vision plan, agree to participate in a discount program sponsored by the vision plan.
(4)(b) A contract between a vision service provider and a vision plan to provide a covered service may not be contingent on whether the vision service provider agrees to participate in a discount program sponsored by the vision plan.
(4)(c) Regardless of whether a vision service provider participates in a discount program sponsored by the vision plan, a vision plan shall offer equal treatment to a vision service provider under contract with the vision plan to provide a covered service, regarding:
(4)(c)(i) promotional treatment;
(4)(c)(ii) marketing benefits;
(4)(c)(iii) materials; and
(4)(c)(iv) contract terms for providing a covered service.
(5) Notwithstanding Subsection (4)(c), a vision plan may, when providing a typically-formatted list of vision service providers that accept the vision plan, identify whether a vision service provider participates in a discount program sponsored by the vision plan.

Legislative History

Amended by Chapter 193, 2019 General Session