VISION BENEFIT MANAGERS

Full Bill Text

SB3707 Enrolled LRB104 20689 JDS 34188 b 1 AN ACT concerning regulation. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The Vision Care Plan Regulation Act is amended 5 by changing Sections 5, 10, 15, 20, 35, and 40 and by adding 6 Sections 17, 18, 45, 50, and 55 as follows: 7 (215 ILCS 161/5) 8 Sec. 5. Definitions. As used in this Act: 9 "Administrator" has the meanings given to that term in 10 Sections 370g and 511.101 of the Illinois Insurance Code. 11 "Affiliate" has the meaning given to that term in 12 subsection (a) of Section 131.1 of the Illinois Insurance 13 Code. 14 "Covered materials" means materials for which 15 reimbursement from an enrollee's the vision care plan is 16 provided to an eye care provider or for which reimbursement is 17 provided to by an enrollee under a vision care enrollee's plan 18 contract or for which a reimbursement would be available but 19 for the application of the enrollee's plan contractual 20 limitation of deductibles, copayments, or coinsurance. 21 "Covered materials" includes lens treatment or coatings added 22 to a spectacle lens if the base spectacle lens is a covered 23 material. SB3707 Enrolled - 2 - LRB104 20689 JDS 34188 b 1 "Covered services" means services for which reimbursement 2 from an enrollee's the vision care plan is provided to an eye 3 care provider or for which reimbursement is provided to by an 4 enrollee under a vision care enrollee's plan contract or for 5 which a reimbursement would be available but for the 6 application of the enrollee's contractual plan limitation of 7 deductibles, copayments, or coinsurance regardless of how the 8 benefits are listed in an enrollee's benefit plan's definition 9 of benefits. 10 "Enrollee" means any individual enrolled in a vision care 11 plan provided by a group, employer, or other entity that 12 purchases or supplies coverage for a vision care plan. 13 "Excepted benefits" has the meaning given to that term in 14 subsection (c) of Section 2791 of the federal Public Health 15 Service Act (42 U.S.C. 300gg-91(c)) and federal regulations 16 promulgated in accordance with that subsection. 17 "Eye care provider" means a doctor of optometry licensed 18 pursuant to the Illinois Optometric Practice Act of 1987 or a 19 physician licensed to practice medicine in all of its branches 20 pursuant to the Medical Practice Act of 1987. 21 "Fee schedule" means documents that provide the 22 predetermined rates or allowed amounts for covered services 23 and covered materials, paid to the eye care provider by the 24 vision care organization. 25 "Health insurance coverage" has the meaning given to that 26 term in Section 5 of the Illinois Health Insurance Portability SB3707 Enrolled - 3 - LRB104 20689 JDS 34188 b 1 and Accountability Act. 2 "Health insurance issuer" or "issuer" has the meaning 3 given to that term in Section 5 of the Illinois Health 4 Insurance Portability and Accountability Act. 5 "Materials" means ophthalmic devices, including, but not 6 limited to: 7 (i) lenses, devices containing lenses, ophthalmic 8 frames, and other lens mounting apparatus, prisms, lens 9 treatments, and coatings; 10 (ii) contact lenses and prosthetic devices that 11 correct, relieve, or treat defects or abnormal conditions 12 of the human eye or adnexa; and 13 (iii) any devices that deliver medication or other 14 therapeutic treatment to the human eye or adnexa. 15 "Provider agreement" means the contractual relationship 16 between a vision care organization and an eye care provider 17 setting forth the terms and conditions under which covered 18 services and covered materials are provided to an enrollee 19 under the vision care plan, including but not limited to, 20 provider manuals, policies and procedures, fee schedules, 21 dispute resolution processes, and any documents incorporated 22 by reference. 23 "Services" means the professional work performed by an eye 24 care provider. 25 "Subcontractor" means any company, group, affiliate, or 26 third-party entity, including agents or , servants , that SB3707 Enrolled - 4 - LRB104 20689 JDS 34188 b 1 performs or administers functions or services on behalf of the 2 vision care organization to execute or , partially owned or 3 wholly owned subsidiaries and controlled organizations, that 4 the vision care plan contracts with to supply services or 5 materials for an eye care provider or enrollee to fulfill the 6 benefit plan of a vision care plan or a vision care discount 7 plan. The location of the person's or entity's domicile, 8 whether in Illinois or a foreign or alien jurisdiction, does 9 not affect the person's or entity's status as a subcontractor . 10 "Vision care discount plan" means a policy, contract, or 11 agreement offered by a vision care organization to an enrollee 12 that solely provides for a discount for noncovered vision care 13 services or materials. 14 "Vision care organization" means an administrator or 15 issuer entity formed under the laws of this State or another 16 state that issues or administers a vision care plan. 17 "Vision care plan" means a policy, certificate, contract, 18 or other plan of health insurance coverage, whether excepted 19 benefits or any other coverage that creates, promotes, sells, 20 provides, advertises, or administers an integrated or 21 stand-alone plan that provides coverage for covered services 22 and covered materials. 23 (Source: P.A. 103-482, eff. 8-4-23; 104-417, eff. 8-15-25.) 24 (215 ILCS 161/10) 25 Sec. 10. Noncovered services. SB3707 Enrolled - 5 - LRB104 20689 JDS 34188 b 1 (a) No vision care organization that issues, delivers, 2 amends, or renews a provider agreement vision care plan on or 3 after the effective date of this amendatory Act of the 104th 4 General Assembly shall issue a contract that requires an eye 5 care provider, as a condition of participation in the vision 6 care plan, to provide services or materials to an enrollee at a 7 fee set by the vision care plan unless the services or 8 materials are covered services or covered materials under the 9 vision care plan. De minimis reimbursements shall not qualify 10 a service or material as a covered service or a covered 11 material under this Act. 12 (b) An eye care provider who chooses not to accept as 13 payment an amount set by a vision care plan for services or 14 materials that are not covered services or covered materials 15 shall post, in a conspicuous place, a notice stating the 16 following: "IMPORTANT: In accordance with State law, this This 17 eye care provider may choose does not to accept discounts the 18 fee schedule set by your insurer for noncovered vision care 19 services and noncovered vision care materials that are not 20 covered benefits under your plan and instead charges his or 21 her normal fee for those services and materials . However, This 22 eye care provider will provide you with an estimated cost for 23 each noncovered service or noncovered material will be made 24 available upon your request." 25 (Source: P.A. 103-482, eff. 8-4-23.) SB3707 Enrolled - 6 - LRB104 20689 JDS 34188 b 1 (215 ILCS 161/15) 2 Sec. 15. Fees for covered services and covered materials. 3 (a) Fees paid under a vision care plan for covered 4 services and covered materials, regardless of the supplier or 5 optical lab used to obtain materials, shall be reasonable and 6 shall be clearly listed on a fee schedule that has been 7 provided to the eye care provider before entering into a 8 provider agreement contract with the vision care organization. 9 Fees paid for materials supplied by a non-network lab are not 10 required to be identical to fees paid for materials ordered 11 through a network lab, but non-network lab fees shall be 12 reasonable. 13 (b) A vision care organization shall, before entering into 14 a provider agreement, inform the eye care provider by email 15 or, if requested by the eye care provider, by mail, on how to 16 access the fee schedule. A vision care organization may make 17 this information available by mail, email, or website listing. 18 (c) A vision care organization shall make an updated copy 19 of a fee schedule available to the eye care provider every 20 calendar quarter. Nothing in this subsection precludes a 21 vision care organization from making the fee schedule 22 available to the eye care provider more frequently than every 23 calendar quarter or available at all times. 24 (Source: P.A. 103-482, eff. 8-4-23.) 25 (215 ILCS 161/17 new) SB3707 Enrolled - 7 - LRB104 20689 JDS 34188 b 1 Sec. 17. Payments. 2 (a) A vision care organization shall comply with Section 3 355.6 of the Illinois Insurance Code. 4 (b) A vision care organization shall not prohibit an eye 5 care provider from offering a cash payment option to the 6 enrollee if the cash payment option is less costly to the 7 enrollee than the total out-of-pocket cost of the covered 8 service or covered material. 9 (215 ILCS 161/18 new) 10 Sec. 18. Vision care plan benefits. A vision care 11 organization shall clearly list, in the schedule of benefits 12 and vision care plan documents provided to an enrollee and eye 13 care provider, the cost-sharing amounts associated with 14 covered materials and covered services. 15 (215 ILCS 161/20) 16 Sec. 20. Misrepresentation. 17 (a) A vision care organization and its officers, 18 directors, agents, and employees are subject to the provisions 19 of Sections 149 , and 154.6 , and 424 of the Illinois Insurance 20 Code. 21 (b) The provisions of this Act apply to any limited health 22 service organization certified under the Limited Health 23 Service Organization Act that is a vision care organization. 24 (c) (b) Incorporation by reference in this Act to specific SB3707 Enrolled - 8 - LRB104 20689 JDS 34188 b 1 laws of this State shall not be construed to exempt a vision 2 care organization or vision care plan from otherwise 3 applicable laws that are not specifically referenced in this 4 Act. 5 (Source: P.A. 103-482, eff. 8-4-23.) 6 (215 ILCS 161/35) 7 Sec. 35. Modification of a provider agreement plan . 8 (a) The terms, fees, discounts, provider manuals, or 9 reimbursement rates in a provider agreement vision care plan 10 may not be changed during the term of the provider agreement 11 contract unless mutually agreed to in writing by the eye care 12 provider and the vision care organization that issued the 13 provider agreement vision care plan . However, a change 14 proposed to a provider agreement vision care plan by the 15 vision care organization shall become effective if the eye 16 care provider fails to respond to the vision care organization 17 within 60 days after verification of receipt of notice of the 18 proposed changes , as provided in subsections (b) and (c) . 19 (b) Notification of any proposed changes to the provider 20 agreement, and the details in the provider agreement, shall be 21 sent to the eye care provider by electronic communication with 22 verification upon receipt, or upon request of the eye care 23 provider, through certified mail. 24 (c) A vision care organization shall provide to the eye 25 care provider reasonable access to agreement terms, policy SB3707 Enrolled - 9 - LRB104 20689 JDS 34188 b 1 manuals, fee schedules, and any other policies and procedures 2 referenced in the agreement or proposed amendments to the 3 agreement. As used in this subsection, "reasonable access" 4 includes making this information available upon request by 5 mail, email, or website listing. 6 (d) The term of a provider agreement may not exceed 2 years 7 unless a different term length is mutually agreed to in 8 writing by all parties. 9 (e) (b) The terms of a provider agreement vision care plan 10 contract that is amended, delivered, issued, or renewed after 11 the effective date of this amendatory Act of the 104th General 12 Assembly Act shall comply with the provisions of this Act. 13 (Source: P.A. 103-482, eff. 8-4-23.) 14 (215 ILCS 161/40) 15 Sec. 40. Prohibitions; medical plan preconditions. 16 (a) No vision care organization that issues, delivers, 17 amends, or renews a provider agreement vision care plan on or 18 after the effective date of this amendatory Act of the 104th 19 General Assembly shall issue a provider agreement vision care 20 plan contract that requires: 21 (1) an eye care provider to participate in contract 22 with a plan that offers supplemental or specialty health 23 care services as a condition of entering into or 24 maintaining a provider agreement relating to contracting 25 with a plan that offers basic health services; or SB3707 Enrolled - 10 - LRB104 20689 JDS 34188 b 1 (2) an eye care provider to participate in contract 2 with a vision care plan as a condition to participation in 3 a medical plan or in-network. 4 (b) A vision care organization plan may enter into an 5 agreement with a health care plan to deliver routine vision 6 care services that are covered under the enrollee's plan. 7 (c) A vision care organization plan may administer act as 8 a network regarding routine vision care services offered by a 9 health care plan. 10 (Source: P.A. 103-482, eff. 8-4-23.) 11 (215 ILCS 161/45 new) 12 Sec. 45. Participation in vision care discount plans. A 13 vision care organization shall not require an eye care 14 provider to contract for services under a vision care discount 15 plan as a condition of contracting for services under a 16 provider agreement. 17 (215 ILCS 161/50 new) 18 Sec. 50. Prohibition on a security interest. A vision care 19 organization shall not require an eye care provider to 20 establish a security interest in any property or assets of the 21 eye care provider, including pertaining to the eye care 22 provider's practice. 23 (215 ILCS 161/55 new) SB3707 Enrolled - 11 - LRB104 20689 JDS 34188 b 1 Sec. 55. Nonretaliation. A vision care organization may 2 not retaliate against an eye care provider for exercising any 3 rights under this Act, including, but not limited to: 4 (1) communicating with the Department of Insurance, 5 federal regulators, State or federal legislators, or 6 professional associations regarding the enforcement or 7 interpretation of this Act; or 8 (2) filing a complaint or report with the Department 9 of Insurance regarding the enforcement of this Act or any 10 other provisions of the Illinois Insurance Code or the 11 Illinois Administrative Code. 12 (815 ILCS 505/2CCCC rep.) 13 Section 90. The Consumer Fraud and Deceptive Business 14 Practices Act is amended by repealing Section 2CCCC. 15 Section 99. Effective date. This Act takes effect January 16 1, 2027.