Oklahoma § 36-3634.11 - Coverage of vision care or medical diagnosis and

§ 36-3634.11. Coverage of vision care or medical diagnosis and

treatment services – Referral to optometrists – Equal compensation.

A. Any health benefit plan which offers services for vision

care or medical diagnosis and treatment for the eye shall allow

optometrists to be providers of those services.

B. With respect to optometric services, any health benefit plan

which uses a gatekeeper or equivalent for referrals for services for

vision care or for medical diagnosis and treatment of the eye shall

require such covered services be provided on a referral basis within

the medical group or network at the request of an enrollee who has a

condition requiring vision care or medical diagnosis and treatment

of the eye if:

1. A referral is necessitated in the judgment of the primary

care physician; and

Oklahoma Statutes - Title 36. Insurance

2. Treatment for the condition falls within the licensed scope

of practice of an optometrist.

C. Each health benefit plan shall have a defined set of

standards and procedures for selecting providers, including

specialists, to serve enrollees. The standards and procedures shall

be drafted in such a manner that they are applicable to all

categories of providers and shall be utilized by the health benefit

plan in a manner that is without bias for or discrimination against

a particular category or categories of providers.

D. No health benefit plan shall require a provider to have

hospital privileges if hospital privileges are not usual and

customary for the services the provider provides.

E. Health benefit plans shall provide that optometrists be

equally compensated for covered services and procedures provided to

an insured on the basis of charges prevailing in the same

geographical area or in similar-sized communities for similar

services and procedures as provided in the Health Care Freedom of

Choice Act, if the services are within the scope of practice of

optometry.

F. Nothing in this section shall be construed to:

1. Prohibit a health benefit plan which offers services for

vision care or medical diagnosis and treatment for the eye from

determining the adequacy of the size of its network;

2. Prohibit an optometrist from agreeing to a fee schedule;

3. Limit, expand, or otherwise affect the scope of practice of

optometry; or

4. Alter, repeal, modify or affect the laws of this state

except where such laws are in conflict or are inconsistent with the

express provisions of this section.

G. Existing health benefit plans shall comply with the

requirements of this section upon issuance or renewal on or after

the effective date of this act.

H. As used in this section, "health benefit plan" means

individual or group hospital or medical insurance coverage, a notfor-profit hospital or medical service or indemnity plan, a prepaid

health plan, a health maintenance organization plan, a preferred

provider organization plan, the State and Education Employees Group

Health Insurance Plan, any program funded under Title XIX of the

Social Security Act or such other publicly funded program, and

coverage provided by a Multiple Employer Welfare Arrangement (MEWA)

or employee self-insured plan except as exempt under federal ERISA

provisions.

Added by Laws 2000, c. 54, § 1, eff. Nov. 1, 2000.