§ 23-99-303 - Requirements for health benefit plans.
23-99-303. Requirements for health benefit plans.
A health benefit plan that includes, or may include, eye and/or vision care benefits shall:
(1) Include all primary eye care providers who are selected by covered persons of the plan for the provision of all eye and/or vision care benefits provided by the plan;
(2) Permit any licensed optometrist or ophthalmologist who agrees to abide by the terms, conditions, reimbursement rates, and standards of quality of the health benefit plan to serve as a primary eye care provider to any person covered by that plan;
(3) Guarantee that all covered persons who are eligible for eye and/or vision care benefits under a health benefit plan shall have direct access to the primary eye care provider of their choice independent of, and without referral from, any other provider or entity;
(4) (A) Assure that those plans utilizing a gatekeeper system shall designate the primary eye care provider as the gatekeeper who shall provide basic patient care and coordinate diagnostic testing, indicated treatment, and specialty referral for those covered persons in the provision of eye and/or vision care benefits.
(B) (i) Nothing in this subchapter shall prevent a covered person from having direct access to that person's primary care provider, or gatekeeper, for the treatment of eye disease or injury and being reimbursed in accordance with the terms and fee schedule of the health benefit plan.
(ii) However, nothing contained in this subchapter shall require payment of the monthly patient management fee by the Arkansas Medicaid Program to a primary eye care provider gatekeeper;
(5) Not discriminate between individual providers or classes of providers in the amount of reimbursement, copayment, or other financial compensation for the same or essentially similar services provided by the health benefit plan;
(6) Not promote or recommend any individual provider or class of providers to a covered person by any method or means;
(7) Assure that all primary eye care providers selected by persons covered by a health benefit plan are included on the list of participating providers of the plan;
(8) Assure that an adequate number of primary eye care providers are included to guarantee reasonable accessibility, timeliness of care, convenience, and continuity of care to covered persons; and
(9) Make available to covered persons a listing of all primary eye care providers, their practice locations, and telephone numbers on a regular, timely basis.