24-A §4314. Access to eye care providers - Maine Statutes

Title 24-A: MAINE INSURANCE CODE

Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT HEADING: PL 1997, C. 792, §2 (RPR)

Subchapter 1: HEALTH PLAN REQUIREMENTS HEADING: PL 1997, C. 792, §2 (NEW)

§4314. Access to eye care providers

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.

A. "Eye care provider" means a participating provider who is an optometrist licensed to practice optometry pursuant to Title 32, chapter 34-A, or an ophthalmologist licensed to practice medicine pursuant to Title 32, chapter 48. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

B. "Eye care services" means those urgent health care services related to the examination, diagnosis, treatment and management of conditions, illnesses and diseases of the eye and related structures that are provided to treat conditions, illnesses or diseases of the eye that if not treated within 24 hours present a serious risk of harm. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

[ 2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF) .]

2. Coverage of eye care services. A carrier that provides coverage for eye care services as part of a health plan shall provide coverage for eye care services in accordance with the following.

A. An enrollee may receive eye care services from an eye care provider participating in the enrollee's health plan without the prior approval or authorization of the enrollee's primary care provider for a maximum of 2 visits, one initial visit and one follow-up visit, for each occurrence requiring urgent care as described in subsection 1, paragraph B. A carrier may not retrospectively deny coverage under this section on the basis that the eye care services received by the enrollee did not meet the requirements of subsection 1, paragraph B. In order to receive continuing benefits for treatment related to the initial visit, an enrollee must receive the approval of the enrollee's primary care provider for any visit after the 2nd visit. Within 3 working days of the initial visit, the eye care provider shall send to the enrollee's primary care provider a report containing the enrollee's complaint, related history, examination results, initial diagnosis and recommendations for treatment. If the eye care provider does not send a report to the primary care provider within 3 working days, the carrier is not obligated to provide benefits for the self-referred visits under this paragraph and the enrollee is not liable to the eye care provider for any unpaid fees. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

B. A carrier shall ensure that all eye care providers participating in the carrier's health plans are included on any publicly accessible list of participating providers for the carrier. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

C. A carrier shall allow each eye care provider participating in the carrier's health plans to furnish covered eye care services to enrollees without discrimination between classes of eye care providers and to provide the eye care services permitted by the eye care provider's license. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

[ 2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF) .]

3. Prohibitions. A carrier may not:

A. Impose a deductible or coinsurance for eye care services that is greater than the deductible or coinsurance imposed for other health care services under a health plan; or [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

B. Require an eye care provider to hold hospital privileges as a condition of participation as a provider under a health plan. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

[ 2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF) .]

4. Construction. This section may not be construed as:

A. Requiring coverage for routine eye examinations; [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

B. Creating coverage for any health care service that is not otherwise covered under the terms of a health plan; [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

C. Requiring a carrier to include as a participating provider every willing provider or health care professional who meets the terms and conditions of a health plan; [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

D. Preventing an enrollee from seeking eye care services from the enrollee's primary care provider in accordance with the terms of the enrollee's health plan; [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

E. Increasing or decreasing the scope of practice of optometry or ophthalmology as defined in Title 32; [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

F. Requiring eye care services to be provided in a hospital or similar health care facility; or [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

G. Notwithstanding the definition of eye care services in subsection 1, paragraph B, prohibiting a carrier from requiring an enrollee to receive prior approval or authorization from a primary care provider for any subsequent surgical procedures. [2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF).]

[ 2001, c. 408, §1 (NEW); 2001, c. 408, §2 (AFF) .]

5. Application. The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.

[ 2003, c. 517, Pt. B, §33 (NEW) .]

SECTION HISTORY

2001, c. 408, §1 (NEW). 2001, c. 408, §2 (AFF). 2003, c. 517, §B33 (AMD).