Brief Description: Establishing requirements for primary medical eye care.

Sponsors: Senate Committee on Health & Long-Term Care (originally sponsored by Senators Keiser, Franklin, Kastama, Fairley, Marr, Delvin, Kohl-Welles, Brandland, Schoesler and Rasmussen).

Hearing Date: 2/25/08

Staff: Chris Cordes (786-7103).

Background:

Health carriers, including disability carriers, health care service contractors, and health maintenance organizations, that offer health plans are regulated by state statute and by rules adopted by the Insurance Commissioner. Under Insurance Commissioner rules, a managed care plan is a health plan that coordinates the provision of health care services to enrollees through a primary care provider and a network. The primary care provider supervises, coordinates, or provides initial or continuing care to the enrollee. Depending on the plan, the primary care provider may be responsible for initiating referrals for specialty care.

By state law, health carriers must offer enrollees in a health plan an adequate choice among health care providers. Health carriers must allow an enrollee to choose, from a list of participating providers, a primary care provider who is accepting new patients. On request, a health carrier must provide an enrollee with written plan information, including both the procedures an enrollee must follow to consult a provider other than the primary care provider and who must authorize the referral. If specialty care is warranted, a health carrier must provide for an appropriate and timely referral to a choice of specialists.

Summary of Bill:

Beginning January 1, 2009, health carriers must meet various requirements related to enrollees' access to primary medical eye care providers for health care plans providing coverage for primary medical eye care. "Primary medical eye care" is defined to mean health care services within the scope of optometry practice, whether provided by an optometrist, a physician, or an osteopathic physician.

Access to Primary Medical Eye Care Providers

A health benefit plan that includes primary medical eye care must:

• provide enrollees with a complete list of health care providers contracted or subcontracted to provide primary medical eye care to the enrollees;
• make all these contracted providers available to enrollees, subject to service area requirements; and
• permit enrollees to access any of these contracted providers on the same terms as the enrollee has access to his or her primary care provider.

Enrollee point-of-service cost-sharing for primary medical eye care may not be more than for services provided by the primary medical provider.

Referral for Specialty Eye Care

A primary medical eye care provider's referral for specialty eye care is deemed equivalent to a referral by a primary care provider for all purposes including point-of-service cost-sharing.

A health carrier may require notice of the referral to a gatekeeper or the patient's medical home.

Payment for Services

Health care providers contracted with a health carrier, either directly or through a subcontract, to provide primary medical eye care to enrollees must be paid for covered services included in the health benefit plan, subject to contract conditions.

Other Provisions

These provisions do not require any health plan to include coverage for any condition, including primary medical eye care, or expand the scope of practice for any eye care provider.

Appropriation: None.

Fiscal Note: Available on original bill.

Effective Date: The bill takes effect 90 days after adjournment of session in which bill is passed.