To amend chapter 376, RSMo, by adding four new sections relating to direct patient access to primary eye care providers.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI,

AS FOLLOWS:

Section A. Chapter 376, RSMo, is amended by adding thereto four new sections, to be known as sections 376.1240, 376.1243, 376.1247 and 376.1249, to read as follows:

376.1240. Sections 376.1240 to 376.1249 shall be known as the "Patient Access to Primary Eye Care Providers Act".

376.1243. As used in sections 376.1240 to 376.1249, the following terms mean:

(1) "Class of primary eye care provider", an ophthalmologist or optometrist;

(2) "Covered person", an individual or family enrolled in a health benefit plan, program, policy or agreement with a health care insurer and on whose behalf the insurer is obligated to provide medical and/or vision care services or to pay or make reimbursement for such services;

(3) "Covered services", those health care services, including medical and vision care services or materials, which a health care insurer is obligated to pay for or provide to covered persons under a health benefit plan;

(4) "Health benefit plan", any public or private health plan, program, policy or agreement implemented in the state of Missouri that provides medical and/or vision care benefits to covered persons, including payments and reimbursements, and including workers' compensation payments or reimbursements;

(5) "Health care insurer", any entity including, but not limited to, insurance companies, hospital and medical services corporations, health maintenance organizations, preferred provider organizations, and physician hospital organizations authorized by the state of Missouri to offer or provide health benefit plans, programs, policies, subscriber contracts or any other agreements of a similar nature which compensate or indemnify health care providers for furnishing health care services;

(6) "Ophthalmologist", a physician licensed pursuant to chapter 334, RSMo, whose practice is limited to medical and surgical care of the eye and visual system and routine vision care;

(7) "Optometrist", a doctor of optometry licensed pursuant to chapter 336, RSMo, engaged in the practice of optometry;

(8) "Primary care physician", a covered person's primary care provider in a caregiver system;

(9) "Primary care provider system", a system of administration used by a health benefit plan in which a primary care provider furnishes basic patient care, including diagnosis, treatment, coordination of care, and referral for specialty care for persons covered by a health benefit plan;

(10) "Primary eye care", those health care services and materials relating to medical care of the eye and related structures and vision care services which a health care insurer is obligated to pay for or provide to covered persons under a health benefit plan;

(11) "Primary eye care providers", ophthalmologists and optometrists.

376.1247. A health benefit plan that includes medical or vision care benefits shall:

(1) Assure covered persons direct access to primary eye care providers without first requiring a referral by a primary care physician for primary eye care;

(2) Not penalize or discriminate against a covered person who seeks medical eye care or vision care directly from a primary eye care provider on the health benefit plan panel;

(3) Allow a covered person to seek care from primary eye care providers who are not included within a preferred provider list of a health benefit plan; however, the health benefit plan may require a reasonable higher copayment by the covered person for out-of-plan care as implemented by regulations issued under section 536.024, RSMo, by the department of insurance;

(4) Not set professional fees or reimbursement for the same or similar services in a manner that discriminates against an individual primary eye care provider or a class of primary eye care providers;

(5) Not promote or recommend any class of providers to a covered person;

(6) Assure all primary eye care providers belonging to a health benefit plan are included on any publicly accessible list of participating providers in the plan;

(7) Assure that an adequate number of primary eye care providers are included in a health benefit plan which includes primary eye care, to guarantee reasonable accessibility, timeliness of care, convenience and continuity of care to covered persons;

(8) Allow the primary eye care provider without discrimination between classes to furnish covered primary care services to covered persons;

(9) Neither require a primary eye care provider to hold hospital privileges nor impose any other condition or restriction upon such providers which would have the practical effect of excluding an individual or class of primary eye care providers from participation in a health benefit plan.

376.1249. 1. Nothing in sections 376.1240 to 376.1249 shall preclude any covered person from receiving emergency medical eye care nor preclude any covered person from receiving treatment for covered services from the person's personal physician in accordance with the terms of the health benefit plan.

2. Any person adversely affected by a violation of sections 376.1240 to 376.1249 by a health care insurer may bring an action in a court of competent jurisdiction for injunctive relief against such insurer and upon prevailing, in addition to any injunctive relief that may be granted, shall recover from such insurer damages of not less than one thousand dollars and attorney fees and court costs.