Prohibited contract provisions in contracts between carriers and eye care providers - definitions

(a) Provide services or materials to a covered person at a fee set by, or subject to the approval of, the carrier or entity unless the services or materials are covered services or covered materials under the covered person's vision care plan and the amount of coverage is neither nominal nor de minimis;

(b) Charge a covered person for a noncovered service or noncovered materials in an amount less than the usual and customary amount that the eye care provider charges individuals who do not have coverage for such materials and services; or

(c) Participate, as a condition of participation in a vision care plan, in any of the carrier's or entity's other vision plan networks.

(2) A carrier or entity shall not change the terms of the contract between the carrier or entity and an eye care provider without communication with the eye care provider.

(3) If the commissioner determines that a carrier or entity has not complied with this section, the commissioner shall do one or both of the following:

(a) Institute a corrective action plan for the carrier to follow;

(b) Use any of the commissioner's enforcement powers to obtain the carrier's or entity's compliance with this section.

(4) For purposes of this section:

(a) Covered materials means materials for which reimbursement is available under a covered person's vision care plan, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.

(b) Covered services means eye care provider services for which reimbursement is available under a covered person's vision care plan, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.

(c) Eye care provider means:

(I) An optometrist licensed to practice under article 275 of title 12; or

(II) An ophthalmologist licensed to practice under article 240 of title 12.

(e) Usual and customary amount means an amount established pursuant to an appropriate methodology that is based on generally accepted industry standards and practices.

(f) Vision care plan means:

(I) A vision care insurance policy or contract that provides vision benefits to a covered person; and

(II) A vision discount plan that provides discounts to vision benefits to a covered person.

(5) This section does not apply to an entity offering a vision discount plan to the entity's members if the entity is not primarily engaged in the business of offering vision care plans.