AI-assisted research summary: A managed care plan may not control or interfere with how optometrists practice, what vendors or software they choose, what patient information is demanded for claims, or how reimbursement is paid. Optometrists must disclose certain business interests to patients.
Sec. 1451.156. CERTAIN CONDUCT PROHIBITED. (a) A managed care plan, as described by Section 1451.152(a), may not directly or indirectly: (1) control or attempt to control the professional judgment, manner of practice, or practice of an optometrist or therapeutic optometrist; (2) employ an optometrist or therapeutic optometrist to provide a vision care product or service as defined by Section 1451.155; (3) pay an optometrist or therapeutic optometrist for a service not provided; (4) reimburse an optometrist or therapeutic optometrist a different amount for a covered product or service as defined by Section 1451.155 because of the optometrist's or therapeutic optometrist's choice of: (A) optical laboratory; (B) source or supplier of: (i) contact lenses; (ii) ophthalmic lenses; (iii) ophthalmic glasses frames; or (iv) covered or uncovered products or services; (C) equipment used for patient care; (D) retail optical affiliation; (E) vision support organization; (F) group purchasing organization; (G) doctor alliance; (H) professional trade association membership; (I) affiliation with an arrangement defined as a franchise by 16 C.F.R. Part 436; (J) electronic health record software, electronic medical record software, or practice management software; or (K) third-party claim-filing service, billing service, or electronic data interchange clearinghouse company; (5) restrict, limit, or influence an optometrist's or therapeutic optometrist's choice of sources or suppliers of services or materials, including optical laboratories used by the optometrist or therapeutic optometrist to provide services or materials to a patient; (6) restrict, limit, or influence an optometrist's or therapeutic optometrist's choice of electronic health record software, electronic medical record software, or practice management software; (7) restrict, limit, or influence an optometrist's or therapeutic optometrist's choice of third-party claim-filing service, billing service, or electronic data interchange clearinghouse company; (8) restrict or limit an optometrist's or therapeutic optometrist's access to a patient's complete plan coverage information, including in-network and out-of-network coverage details; (9) apply a chargeback, as defined by Section 1451.155, to a patient, optometrist, or therapeutic optometrist if the chargeback is for a covered product or service that the managed care plan does not incur the cost to produce, deliver, or provide to the patient, optometrist, or therapeutic optometrist; (10) require an optometrist or therapeutic optometrist to provide a covered product at a loss; (11) require an optometrist or therapeutic optometrist to disclose a patient's confidential or protected health information unless the disclosure is authorized by the patient or permitted without authorization under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.) or under Section 602.053; (12) require an optometrist or therapeutic optometrist to disclose or report a medical history or diagnosis as a condition to file a claim, adjudicate a claim, or receive reimbursement for a routine or wellness vision eye exam; (13) require an optometrist or therapeutic optometrist to disclose or report a patient's glasses prescription, contact lens prescription, ophthalmic device measurements, facial photograph, or unique anatomical measurements as a condition to file a claim, adjudicate a claim, or receive reimbursement for a claim unless the information is needed for the managed care plan to manufacture or cause to be manufactured a covered product that is submitted on the claim; (14) require an optometrist or therapeutic optometrist to disclose any patient information, other than information identified on the version of the Health Insurance Claim Form approved by the National Uniform Claim Committee as of March 1, 2023, as a condition to file a claim, adjudicate a claim, or receive reimbursement for a claim unless the information is needed for the managed care plan to manufacture or cause to be manufactured a covered product that is submitted on the claim; or (15) require an optometrist or therapeutic optometrist to accept a reimbursement payment in the form of a virtual credit card or any other payment method where a processing fee, administrative fee, percentage amount, or dollar amount is assessed to receive the reimbursement payment, except in the case of a nominal fee assessed by the optometrist's or therapeutic optometrist's bank to receive an electronic funds transfer. (b) Subsection (a)(2) does not prohibit a managed care plan from employing an optometrist or therapeutic optometrist for utilization review or for operations of the managed care plan. (c) Subsection (a)(3) does not prohibit the use of capitation as a method of payment. (d) Repealed by Acts 2023, 88th Leg., R.S., Ch. 898 (H.B. 1696), Sec. 10, eff. September 1, 2023. (e) An optometrist or therapeutic optometrist must disclose to a patient any business interest the optometrist or therapeutic optometrist has in an out-of-network supplier or manufacturer to which the optometrist or therapeutic optometrist refers the patient. (f) This section shall be liberally construed to prevent managed care plans from controlling or attempting to control the professional judgment, manner of practice, or practice of an optometrist or therapeutic optometrist. Added by Acts 2015, 84th Leg., R.S., Ch. 1271 (S.B. 684), Sec. 3, eff. September 1, 2015. Amended by: Acts 2023, 88th Leg., R.S., Ch. 898 (H.B. 1696), Sec. 7, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 898 (H.B. 1696), Sec. 8, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 898 (H.B. 1696), Sec. 10, eff. September 1, 2023.