To amend chapter 376, RSMo, relating to direct patient access to primary 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 three new sections, to be known as sections 376.1240, 376.1243 and 376.1247, to read as follows:

     376.1240. Sections 376.1240 to 376.1247 shall be known as the "Patient Access to Primary Eye Care Providers Act".

     376.1243. As used in sections 376.1240 to 376.1247, 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 134, RSMo, who is a graduate of an ophthalmology training program, accredited by the accreditation council for graduate medical education of the American Medical Association or who has been certified by the American Board of Ophthalmology and whose practice includes medical or 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 care giver system;

     (9) "Primary care provider system", a system of administration use 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 for which a health benefit plan is obligated to pay for or provide to covered persons relating to medical or optometric care of the eye and related structures including routine vision care but excluding surgical care;

     (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 in the health benefit plan without first requiring a referral by a primary care physician for primary eye care;

     (2) Allow a covered person to seek eye care directly from a primary eye care provider not on the panel of the health benefit plan, if the plan has provisions for out-of-plan reimbursement for primary health care. The health plan may require a reasonable but higher copayment by the covered person for out-of-plan care;

     (3) 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;

     (4) Not promote or recommend any class of providers to a covered person without cause;

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

     (6) Allow primary eye care providers, without distinction between classes except for good cause, to provide covered primary eye care services to covered persons within the bounds of said primary eye care provider's scope of practice. Health benefit plans may establish a protocol for the administration and delivery of primary eye care services within the plan, as long as direct access for primary eye care is maintained;

     (7) Neither require a primary eye care provider to hold hospital privileges nor impose any unreasonable conditions or restrictions upon such providers which would have the practical effect of excluding, a class of primary eye care providers from participation in a health benefit plan.