Texas § IN.1451.157 - VISION PLAN CONDUCT

§ IN.1451.157. VISION PLAN CONDUCT

VISION PLAN CONDUCT. (a) In this section: (1) "Extrapolation" means a mathematical process or technique used by a vision care plan in the audit of an optometrist or therapeutic optometrist to estimate audit results or findings for a larger batch or group of claims not reviewed by the plan. (2) "Vision care plan" means a limited-scope policy, agreement, contract, or evidence of coverage that provides coverage for eye care expenses but does not provide comprehensive medical coverage. (b) A vision care plan shall not: (1) use extrapolation to complete an audit of a participating optometrist or therapeutic optometrist. Any additional payment due to a participating optometrist or therapeutic optometrist or any refund due to the vision care plan must be based on the actual overpayment or underpayment and may not be based on an extrapolation; or (2) exclude an optometrist or a therapeutic optometrist as a participating practitioner in the plan if the optometrist or therapeutic optometrist satisfies the vision plan's credentialing requirements and agrees to the vision plan's contractual terms. (c) A vision care plan shall describe all medical or vision care products or services covered under the plan using only the standardized codes, names, and definitions published in the Healthcare Common Procedure Coding System, including: (1) Level I codes published by the American Medical Association; and (2) Level II codes published by the Centers for Medicare and Medicaid Services. Added by Acts 2023, 88th Leg., R.S., Ch. 898 (H.B. 1696 ), Sec. 9, eff. September 1, 2023. Amended by: Acts 2025, 89th Leg., R.S., Ch. 348 (H.B. 3211 ), Sec. 3, eff. June 20, 2025.