D.

The provisions, requirements, and prohibitions of this Section shall apply equally to any agent acting on behalf of a health maintenance organization, preferred provider organization, managed care organization, accountablecareorganization,visionbenefitplan,visionbenefitdiscountplan, or other plan or entity that offers an agreement or contract of insurance that provides medical eye care or vision care benefits.

E.

As used in this Section, the definitions provided for in R.S.

22:1809.4 shall apply.

* * * PART XIII.

VISION BENEFIT INSURANCE AND VISION DISCOUNT PLANS §1809.1.

Short title ThisPartshallbecitedasthe"LouisianaVisionPlanTransparencyand Fair Practice Act".

§1809.2.

Purpose The purpose of this Part is to ensure patient access to eye care services andmaterialsthroughtransparentandfairbusinesspracticesbyvisionbenefit managers.

Nothing in this Part shall be construed to expand or limit the scope of practice of any licensed healthcare professional.

The provisions of this Part shallnotapplytomedicalbenefitsprovidedbyaninsurerunderahealthbenefit plan that is not a vision benefit plan or vision benefit discount plan as defined in this Part.

§1809.3.

Legislative findings;

access to eye care services A.

The legislature finds and declares that access to timely, affordable, andappropriateeyecareservicesisamatterofpublic healthandpatientsafety within this state.

B.

The legislature further finds that:

(1) Vision benefit managers and vision benefit plans increasingly Page 3 of 33 Coding:

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404 ENROLLED influence where patients may obtain eye care services and materials, which providers may participate in care delivery, and which treatments or materials may be practically available to patients.

(2) Business practices that steer patients to affiliated providers, restrict providerparticipation,limitaccesstoindependentlaboratoriesorsuppliers,or interferewithclinicaljudgmentmayreduceaccesstocare,particularlyinrural and underserved areas of this state.

(3) Independent eye care providers are essential to maintaining access to vision and medical eye care services for Louisiana residents, including in communities where alternative providers are limited or unavailable.

C.

It is therefore the intent of the legislature that this Part be construed and applied primarily to:

(1) Protect patient access to eye care services and materials.

(2) Preserve the integrity of the doctor-patient relationship.

(3) Ensure that clinical and prescriptive decisions remain under the control of licensed healthcare professionals.

(4) Prevent practices that impair access to care through coercion, steering, or anti-competitive conduct.

(5)Supportacompetitivehealthcareenvironmentthatservesthehealth needs of Louisiana residents.

D.

The provisions of this Part are enacted pursuant to the state's authority to regulate the professional delivery of healthcare services and to protect public health, safety, and welfare.

§1809.4.

Definitions As used in this Part, the following definitions shall apply:

(1)"Chargeback"meansadollaramount,fee,surcharge,rebate,oritem ofvaluethatreduces,modifies,oroffsetsallorpartofthepatientresponsibility, providerreimbursement,allowedamount,orfeescheduleforacoveredservice or covered material.

(2) "Contractual discount" means a percentage reduction from a Page 4 of 33 Coding:

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404 ENROLLED provider'susualandcustomaryrateforcoveredservicesandcoveredmaterials required under a participating provider agreement.

(3)"Coveredmaterial"meansamaterialforwhichreimbursementfrom an insurer, vision benefit manager, or subcontractor is provided to an eye care provider by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance, regardless of how the materials are listed or described in an enrollee's benefit plan's definition of benefits.

(4)"Coveredservice"meanstheprofessionalworkperformedbyaneye care provider for which reimbursement from an insurer, vision benefit manager, or subcontractor is provided to an eye careprovider by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual plan limitations of deductibles, copayments, or coinsurance, regardless of how the services are listed or described in an enrollee's benefit plan's definition of benefits.

(5)"Deminimis"meansequaltozerooranotherwisenegligibleamount.

(6) "Enrollee" means any individual participating in a health benefit plan,visionbenefitplan,orvisionbenefitdiscountplanthatispurchasedbyan individual or provided to an individual by an insurer, company, organization, group, employer, government assistance program, or any other entity that purchases or supplies coverage for a health benefit plan, vision care benefit plan, or vision benefit discount plan.

(7)"Eyecareprovider"meansalicenseddoctorofoptometrypracticing under the authority of R.S.

37:1041 oralicensed medicalorosteopathic doctor as defined in R.S.

37:1262.

(8) "Fee schedule" means the document or system that lists the predetermined payment rates or allowed amounts for covered services or coveredmaterialsanddetermineshowmucheyecareprovidersarereimbursed bytheinsurerorvisionbenefitmanagerandhowmuchpatientsarechargedby the insurer, vision benefit manager, or eye care provider.

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404 ENROLLED (9)"Healthbenefitplan"meansapolicy,contract,oragreementoffered byaninsurer,thirdpartyadministrator,orsubcontractortoanenrolleetopay for, reimburse, discount, or offset healthcare costs.

(10)"Insurer"meansanindividual,corporation,partnership,company, organization, group, health maintenance organization, captive, risk-retention group, self-insurance group, optometricserviceand indemnity corporation, or other entity, whether organized for profit or not-for-profit, whether foreign or domestic, that conducts business in this state and that offers a vision benefit planorprovidescoverageforvision-relatedservicesorvision-relatedmaterials to enrollees.

An entity is considered an insurer for purposes of this Part irrespective of any of the following:

(a) Its corporate form or category of licensure, if applicable, including whether it is otherwise subject to insurance regulations or any other regulations.

(b) Whether it, either directly or indirectly reimburses, indemnifies, pays, or discounts the costs of vision services or vision materials.

(c) Whether it delegates, assigns, or contracts performance of any function regulated by this Part to an affiliate, subsidiary, contractor, intermediary, or network leasing entity.

(11) "Material" means an ophthalmic device including but not limited to lenses, devices containing lenses, artificial intraocular lenses, ophthalmic frames, and other lens mounting apparatus, prisms, lens treatments, and coatings, contact lenses, low vision devices, vision therapy devices, and prostheticdevicesto correct,relieve,or treatdefectsorabnormal conditions of the human eye or the ocular adnexa, or any material allowed to be utilized by the Louisiana State Board of Optometry Examiners and the Louisiana Optometry Practice Act.

(12) "Nominal" means, when there is no corresponding reimbursement inthecurrentyear'spublishedPhysicianFeeSchedulereleasedannuallybythe CentersforMedicareand MedicaidServicesorin thecurrentyear'spublished Page 6 of 33 Coding:

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404 ENROLLED state Medicaid fee schedule, an amount less than the reasonable compensation to the vision care provider rendering the covered service or covered materials, takingintoaccounttheprovider'sdirectandindirectcosts,includingtheactual acquisition costs and actual pro rata overhead costs, and reasonable profit.

(13) "Optometrist" means a licensed doctor of optometry practicing under the authority of R.S.

37:1041.

(14) "Participating eye care provider" means an eye care provider that hasenteredintoacontractualagreementorotherbusinessrelationshipwithan insurer,visionbenefitmanager,third-partyadministrator,orsubcontractorto provide covered services or covered materials.

(15) "Subcontractor" means an individual, company, organization, group, or other entity, including but not limited to an agent, servant, broker, wholesaler, distributor, partially-owned or wholly-owned subsidiary, or controlled organization that is contracted by the vision benefit manager to supply services or materials to another vision benefit manager, eye care provider, or enrollee to execute or fulfill the health benefit plan, vision benefit plan, or vision benefit discount plan of a vision benefit manager.

(16) "Third-party administrator" means an individual, company, organization, group, or other entity that provides services, including but not limitedtoadministrative,operational,regulatory,humanresource,compliance, and claim adjudication services for an insurer, vision benefit manager, individual, company, organization, group, or other entity under a contract or agreement.

(17) "Vision benefit discount plan" means a policy, contract, or agreement offered by an insurer or vision benefit manager to an enrollee that solely provides for a discount for vision care services or materials.

(18)"Visionbenefitplan"meansapolicy,contract,oragreementoffered by an insurerorvision benefitmanagertoan enrolleeto pay for, reimburse, or offset health and vision care costs.

(19) "Vision benefit manager" means an individual, company, Page 7 of 33 Coding:

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404 ENROLLED organization,group,orotherentity,includingbutnotlimitedtoinsurers,third- party administrators, and subcontractors, that creates, promotes, sells, provides, advertises, or administersan integratedorstand-alonevision benefit plan, vision benefit discount plan, or other insurance policy or contract which provides vision benefits or discounts to an enrollee pertaining to the provision of covered services or covered materials.

§1809.5.

Covered and noncovered services and materials A.

No contract or agreement between an insurer or vision benefit manager and an eye care provider may seek to or require that an eye care provider provide services or materials at a fee limited or set by the insurer or vision benefit manager unless the services or materials are defined and reimbursed as covered services or covered materials under the contract or agreement.

B.

An insurer or vision benefit manager shall use only standardized codes, names, descriptions, and definitions published in the Healthcare Common Procedure Coding System, including Current Procedural Terminology codes published by the American Medical Association and Level II codes published by the Centers for Medicare and Medicaid Services, to identify and describe all covered services and covered materials of the vision benefit plan to purchasers and enrollees of the vision benefit plan.

C.

An insurer or vision benefit manager shall use only standardized codes, names, descriptions, and definitions published in the Healthcare Common Procedure Coding System, including all Current Procedural Terminology codes published by the American Medical Association and all Level II codes published by the Centers for Medicare and Medicaid Services, to create and offer a fee schedule of allowed amounts for covered services and covered materials in a contract or agreement between the insurer or vision benefit manager and an eye care provider.

D.

An insurer or vision benefit manager shall not misuse, misrepresent, or change the meaning of any of the standardized codes, names, descriptions, Page 8 of 33 Coding:

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404 ENROLLED anddefinitionspublishedintheHealthcareCommonProcedureCodingSystem, includingallCurrentProceduralTerminologycodespublishedbytheAmerican Medical Association and all Level II codes published by the Centers for Medicare and Medicaid Services.

Any such contractual language, policies, or procedures set by the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

E.Allfeeschedulesinanagreementbetweenaninsurerorvisionbenefit manager and an eye care provider and all reimbursements paid by an insurer or vision benefit manager to an eye care provider for all covered services and covered materials shall not be nominal or de minimis.

There shall be no limitation on the ability of an individual eye care provider or a group of eye careproviderswhopracticeunderasingleEmployerIdentificationNumberor Tax Identification Number to engage in direct negotiations with the insurer or vision benefit manager regarding reimbursement fee schedules, and agreeing to a different fee schedule than the fee schedule provided by the insurer or vision benefit manager to other participating providers or groups.

F.

All fee schedule allowed amounts and all reimbursements paid by an insurerorvisionbenefitmanagerforeachcoveredserviceandcoveredmaterial shall be clearly and individually listed on a fee schedule made available to the eye care provider at all of the following times:

(1) At the time a contract or agreement is offered to the eye care provider by an insurer or vision benefit manager.

(2) Within ten business days from the date an application is made to become a participating eye care provider with the insurer or vision benefit manager by the eye care provider.

(3) At all times via electronic means.

G.

A contract or agreement between an insurer or vision benefit managerandaneyecareprovidershallincludeafeeschedulethatincludesand individually identifies each covered service and covered material and its corresponding allowed amount, reimbursement amount paid to the eye care Page 9 of 33 Coding:

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404 ENROLLED provider,andanyformof acost-sharingamount paidbytheenrolleetotheeye care provider.

H.

Insurers or vision benefit managers shall not advertise, claim, or represent to purchasers or enrollees that services and materials provided by a participatingeyecareproviderarecoveredorincluded, orcoveredorincluded with an additional deductible, copay, or coinsurance, if the insurer or vision benefitmanagerdoes not remitan actualpaymenttotheparticipating eyecare provider as full or partial reimbursement for the service or material.

I.

A service or material provided by a participating eye care provider shall not be designated as a covered service or covered material by the insurer orvisionbenefitmanagerinthedesignofahealthbenefitplan orvisionbenefit planifthereimbursementamounttotheparticipatingeyecareproviderisonly comprised of an enrollee's payment to the participating eye care provider.

J.

Insurersor vision benefit managers shall not condition application to anetworkorparticipationinahealthbenefitplan,visionbenefitplan,orvision benefit discount plan by an eye care provider based on the eye care provider's usual and customary pricing or discounts on usual and customary pricing for servicesormaterialsthatarenotcoveredservicesornotcoveredmaterials.Any such contractual language, policies, or procedures set by the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

K.Aninsurerorvisionbenefitmanagershallnotmakeconditional afee schedule proposed or made to an eye care provider of a health benefit plan, vision benefit plan, or vision benefit discount plan for covered services or coveredmaterialsbasedontheeyecareprovider'susualandcustomarypricing or discounts on usual and customary pricing for services or materials that are not covered services or not covered materials.

Any such contractual language, policies, orproceduressetby the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

L.Acontractoragreementbetweenaninsurerorvisionbenefitmanager and an eye care provider shall not contain a provision, fee schedule, or Page 10 of 33 Coding:

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404 ENROLLED reimbursementamountrequiringtheeyecareprovider,takingintoaccountany applicabledeductibles,copays,coinsurances,discounts,rebates,orchargebacks, to provide covered services or covered materials to an enrollee at a financial loss.

Any such contractual language, policies, or procedures set by the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

M.

All fee schedule-allowed amounts in a provider agreement between an insurer or vision benefit manager and an eye care provider for all covered services and covered materials shall not be less than the current year's published Physician Fee Schedule released annually by the Centers for Medicare and Medicaid Services, unless either of the following occurs:

(1) In the event that a coveredserviceor coveredmaterialdoes not have anallowedamountlistedoriftheallowedamountislistedatzerointhecurrent year's published Physician Fee Schedule released annually by the Centers for MedicareandMedicaidServices,theallowedamountforthecoveredserviceor covered material shall not be less than the current year's published state Medicaid fee schedule rate.

(2)In the event that a coveredserviceor coveredmaterial does not have anallowedamountlistedoriftheallowedamountislistedatzerointhecurrent year's published Physician Fee Schedule released annually by the Centers for Medicare and Medicaid Services or in the current year's published state Medicaid fee schedule rate, the allowed amount for the covered service or covered material shall be reasonable, and not nominal or de minimis.

N.Theperiodoftimeprescribedbyacontractoragreementbetweenan insurer or vision benefit manager and an eye care provider for the insurer or visionbenefitmanagertorecoveranyreimbursementamountfromaneyecare provider shall be the same period of time allowed or required for any insurer or vision benefit manager to remit the applicable reimbursement following an eye care provider's submission of a clean claim for services rendered or materials furnished.

The foregoing shall not limit an insurer or vision benefit Page 11 of 33 Coding:

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404 ENROLLED manager's ability to conduct an audit of claims, in accordancewith the insurer orvisionbenefitplanmanager'swrittenpoliciesandapplicablelaw,intheevent that the insurer or vision benefit manager has a reasonable belief that the eye care provider has engaged in fraud, waste, or abuse.

O.

An insurer or vision benefit manager shall not falsely represent the number of participating providers in a region nor the benefits that comprise a healthbenefitplan,visionbenefitplan,orvisionbenefitdiscountplantoclients, groups, employers, purchasers, companies, enrollees, or prospective enrollees.

Suchactsareconsidereddeceptivetradepracticesandsubjecttopenaltyunder R.S.

22:1964.

P.

An insurer or vision benefit manager shall not promote or use in any marketing or advertising that a covered service or covered material is "free", "no charge", or "complimentary" or any materially similar language to a client, group, employer, purchaser, company, enrollee, or prospective enrollee to purchase services, materials, supplies, or plans from the insurer, vision benefit manager, or affiliate of the insurer or vision benefit manager.

Q.Aninsurerorvisionbenefitmanagershallnotofferenrolleesvarying deductibles, copays, coinsurances, coverage amounts, rebates, gift cards, or other monetary or nonmonetary incentives to obtain covered services, covered materials,noncoveredservices,ornoncoveredmaterialsatanyofthefollowing:

(1) At any particular participating eye care provider.

(2) At a retail establishment owned by, partially owned by, contracted with, or otherwise affiliated with the insurer or vision benefit manager.

(3) At any internet or virtual provider or retailer owned by, partially owned by, contracted with, or otherwise affiliated with the insurer or vision benefit manager.

R.

An insurer or vision benefit manager shall not engage in marketing oradvertisingactivitiesthatmaybemisleadingordeceptivetothepublic.Upon request by a jurisdictional enforcement agency, insurers and vision benefit managersshall submitallinformationregardingallegedsavings and discounts Page 12 of 33 Coding:

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404 ENROLLED offered by affiliates of the insurer or vision benefit manager.

S.

An insurer or vision benefit manager shall remit to the participating eye care provider the contracted reimbursement amount for a covered service or covered material provided to an enrollee if the enrollee is verified to be eligible by the participating eye care provider through customary verification methods of the insurer or vision benefit manager to receivethe covered service or covered material on the date of service.

T.Aparticipatingeyecareproviderisallowed,butnotrequired,tooffer an enrollee the opportunity to pay the participating eye care provider directly forcoveredservicesandcoveredmaterialsifsuchdirectpaymentwouldbeless costlytotheenrolleethanthetotalout-of-pocketcostrequiredunder theterms of a health benefit plan or vision benefit plan.

An eye careprovider may not be subject to an audit, removed from participation in the network, or otherwise penalized or discriminated against in any manner for offering an enrollee the opportunity to pay the participating provider directly under the conditions of this Subsection.

U.

An insurer or vision benefit manager shall not retroactively reverse a reimbursement or withhold a future reimbursement to an eye care provider who relied in good faith on an individual's presented coverage credentials and the customary verification methods of the insurer or vision benefits manager, if the insurer or vision benefit manager later determines that the enrollee was ineligibletoreceivecoveredservicesorcoveredmaterialsonthedateofservice.

V.Aninsurerorvisionbenefitmanagershallnotrequireaparticipating eyecareprovider,purchaser,orenrolleeofahealthbenefitplan, vision benefit plan, or vision benefit discount plan to obtain prior authorization, preauthorization, precertification, or any similar mechanism that restricts the enrolleefromreceivingacoveredserviceorcoveredmaterialrecommendedby the eye care provider and requested by the enrollee.

W.(1) An insurer or vision benefit manager shall not, in the course of adjudicatingaclaimforreimbursementbyaparticipatingeyecareproviderfor Page 13 of 33 Coding:

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404 ENROLLED a covered service or covered material, alter, delete, substitute, or otherwise change any code or modifier submitted by the eye care provider, including downcoding, bundling, orreassigning to adifferentcode,if such changewould reduce payment or otherwise adversely affect the provider or enrollee.

(2) For purposes of this Subsection, the following definitions apply:

(a) "Bundling" means to combine, substitute, or treat two or more distinct services, supplies, or materials reported on the same claim, date, or serviceasincludedwithinasinglecode,package,orglobalservice,anddenying, reducing, or disallowing separate reimbursement for one or more of the codes.

(b)"Downcoding"meanstoalter,delete,substitute,orassignacodethat results in a lower level of service, a lower-valued code, or a reduced reimbursementamountrelativetothecodesubmittedbytheeyecareprovider.

X.

The provisions of this Section shall apply to any affiliate or subcontractor that is used by an insurer or vision benefit manager to supply covered services or covered materials to an eye care provider or enrollee and be subject to all applicable penalties as provided for in this Part.

Y.Aninsurerorvisionbenefitmanagershallneitherrequirenorrequest an eye care provider to opt-in or opt-out of the provisions set forth in this Section.

§1809.6.

Credentialing;

forced participation in panel prohibition;

payment parity A.

No contract or agreement between an insurer or vision benefit manager and an eye care provider shall require an eye care provider to participatewith, be credentialed by, or enterinto acontractoragreementwith anyspecificvisionbenefitplanorvisionbenefitdiscountplanasaconditionfor participationinthehealthbenefitplanprovidernetworkoftheinsurerorvision benefitmanagertoprovidecoveredservicestotheenrolleesofthehealthbenefit plan.

B.

Any insurer or vision benefit manager issuing or renewing a health benefitplan,visionbenefitplan,orvisionbenefitdiscountplan,whichprovides Page 14 of 33 Coding:

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404 ENROLLED benefitsforcoveredservicesorcoveredmaterialsrenderedbyamedicaldoctor or an osteopathic doctor that is within the scope of practice of an optometrist, shall provide no less than the same reimbursement for covered services or covered materials to optometrists as allowed for those covered services or covered materials rendered by medical doctors or osteopathic doctors.

C.

An insurer or vision benefit manager shall apply the same terms and conditions of participation for all eye care providers irrespective of their educational credentials, subject to the permitted scope of practice for the licensee under applicable state law.

D.

An insurer or vision benefit manager shall not require an eye care provider to possess, offer, or sell materials or covered materials in their office as a condition of participation in the provider network of health benefit plan, vision benefit plan, or vision benefit discount plan.

Any such contractual language, policies, or procedures set by the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

E.

If an eye care provider enters into any subcontract agreement with another provider to provide licensed healthcare services to an enrollee or a covered dependent of an enrollee of a health benefit plan, vision benefit plan, or vision benefit discount plan where the subcontracted provider seeks reimbursement from the plan, or enrollee for the subcontracted services, the subcontract agreement must meet all requirements of this Section.

F.TheprovisionsofthisSectionshallapplytoanycontractoragreement an insurer or vision benefit manager enters into with another entity to provide an enrollee with covered services or covered materials.

§1809.7.

Unfair trade practices A.

It is prohibited for an insurer or vision benefit manager that offers multiple health benefit plans, vision benefit plans, or vision benefit discount plans to require an eye care provider, as a condition of participation in the networkforahealthbenefitplan,visionbenefitplan,orvisionbenefitdiscount plan, to participate in the network of any of the insurer's or vision benefit Page 15 of 33 Coding:

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404 ENROLLED manager's other health benefit plans, vision benefit plans, or vision benefit discount plans.

A contract provision or agreement violating this Subsection shall be void.

The penalties and remedies provided for violation of provisions of this Part shall not waive, limit, or otherwise affect the applicability of the Unfair Trade Practices and Consumer ProtectionLaw, R.S.

51:1401 et seq., or any other law providing for civil or criminal penalties or remedies for unfair, deceptive, or unlawful business practices.

B.

It is prohibited for an insurer or vision benefit manager that offers multiple health benefit plans, vision benefit plans, or vision benefit discount plans to withhold participation in the network of one or more of the insurer's or vision benefit manager's other health benefit plans, vision benefit plans, or vision benefit discount plans if the eyecareprovideris alreadyparticipating in the network of one or more of the insurer's or vision benefit manager's health benefit plans, vision benefit plans, or vision benefit discount plans and seeks to participate in the network of the insurer's or vision benefit manager's other health benefit plans, vision benefit plans, or vision benefit discount plans.

C.This Sectionappliestoallplantypesthatahealthbenefitplan, vision benefit plan, or vision benefit discount plan sells, administers, or offers, including but not limited to individually purchased plans and employer-sponsored plans.

§1809.8.

Credentialing and contracting requirements;

acceptance as participating eye care provider A.Aninsurerorvisionbenefitmanagershallincludeallofthefollowing on its website:

(1) A method for an eye care provider to submit an application for inclusion and credentialing as a participating provider in the health benefit plan, vision benefit plan, or vision benefit discount plan.

(2) A description of the credentialing requirements, which shall be reasonable, related to the delivery of covered eye care services, and applied in an objective, uniform, and nondiscriminatory manner.

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404 ENROLLED B.Aninsurer'sorvisionbenefitmanager'sapplicationforinclusionand credentialing as a participating eye care provider in the health benefit plan, vision benefit plan, or vision benefit discount plan shall only require standardized information specified in the current version of the Louisiana Standardized Credentialing Application Form or the current format used by the Council for Affordable Quality Healthcare credentialing application.

C.Aninsurer'sorvisionbenefitmanager'sapplicationforinclusionand credentialingasaparticipatingeyecareproviderinthehealthinsurancebenefit plan, vision benefit plan, or vision benefit discount plan shall impose the same application requirements on each eye care provider.

D.

Not later than the thirtieth business day after the date the insurer or vision benefit manager receives an application from an eye care provider for inclusion as a participating provider in the health benefit plan, vision benefit plan,orvisionbenefitdiscountplan,theinsurerorvisionbenefitmanagershall informtheapplicantofalldefectsandreasonsknownatthetimebytheinsurer or vision benefit manager in the event that the application is deemed to be not correctly completed.

E.

Not later than the fortieth business day after the date the insurer or vision benefit manager receives an application from an eye care provider for inclusion as a participating provider in the health benefit plan, vision benefit, or vision benefit discount planning, the insurer or vision benefit manager shall make available electronically to the eye care provider the proposed participating provider contract, including applicable fee schedules, provider handbooks, and provider manuals.

F.

Not later than the ninetieth business day after the date the insurer or vision benefit manager receives an application from an eye care provider for inclusion as a participating provider in the health benefit plan, vision benefit plan,orvisionbenefitdiscountplan,theinsurerorvisionbenefitmanagershall complete the credentialing determination of the eye care provider, approve or disapprove the application of the eye care provider, and deliver electronically Page 17 of 33 Coding:

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404 ENROLLED a proposed participating provider contract as provided for in this Section for acceptance and signature to the approved eye care provider.

G.

If the application for inclusion and credentialing as a participating provider is denied by the insurer or vision benefit manager, the insurer or vision benefit manager shall deliver to the applicant a detailed explanation for the denial, both electronically and in writing via certified mail.

H.

If the application for inclusion and credentialing as a participating provider is denied by the insurer or vision benefit manager, the eye care provider shall be allowed a reasonable period of time in which to appeal the decision to the insurer or vision benefit manager and provide in the appeal evidence that supports the reconsideration of the denied application.

The insurer or vision benefit managers shall consider, and render a decision on the eye care provider's appeal submission within thirty days of the date of receipt of the submission by the insurer or vision benefit manager.

I.

If the appeal to the application denial for inclusion and credentialing as a participating provider is denied by the insurer or vision benefit manager, the insurer or vision benefit manager shall deliver to the applicant a detailed explanation for the denial of the appeal, both electronically and in writing via certified mail.

J.

If the appeal to the application denial for inclusion and credentialing as a participating provider is denied by the insurer or vision benefit manager, the applicant may appeal the decision to the commissioner and seek a ruling that allows the eye care provider to become a participating provider in the health benefit plan, vision benefit plan, or vision benefit discount plan.

K.

An insurer or vision benefit manager, concurrentwith the electronic delivery of the proposed participating provider contract to the approved eye careprovider,shall provide thename,email address, and phone numberof the representative of the insurer or vision benefit manager to allow the approved eye care provider the opportunity to do all of the following:

(1)Contacttherepresentativebeforesigningthecontractoragreement.

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404 ENROLLED (2)Discusstheproposedcontractwith therepresentativebeforesigning the contract or agreement.

(3) Electronically send the representativemodifications totheproposed contract or agreement before signing the contract.

L.

In the event that the approved eye care provider sends the representative of the insurer or vision benefit manager modifications to the proposedparticipatingprovidercontract,theinsurerorvisionbenefitmanager shall respond to the submission of the approved eye care provider within five business days.

Each subsequent response made by the insurer, vision benefit manager, or approved eye care provider to the other party shall be responded to within five business days by the receiving party.

M.

Once the insurer or vision benefit manager has approved and delivered electronically a proposed participating provider contract, the approved eye care provider has a total allotted time frame of ninety business days to reach agreement with the insurer or vision benefit manager and sign a participating provider contract or agreement.

If the parties fail to reach an agreementandnoparticipatingprovidercontractissignedbytheapprovedeye care provider within the allotted time frame, the insurer or vision benefit manager may retract the participating provider's contract or agreement.

N.Notlater than the twentieth business day after the datetheapproved eye care provider signs a participating provider contract, the insurer or vision benefitmanagershall include thecredentialedand approved eyecareprovider as a participating provider in the health benefit plan, vision benefit plan, or visionbenefitdiscount plan, and list theeyecareproviderwithoutlimitationin all of the plan directories that are available to enrollees and the public.

O.Theearliestthataneyecareprovidermaysubmitanotherapplication to an insurer or vision benefit manager, after a previous approval and subsequent unsuccessful attempt to sign a participating provider contract, is one hundred eighty calendar days from the date of the previous application.

P.Theearliestthataneyecareprovidermaysubmitanotherapplication Page 19 of 33 Coding:

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404 ENROLLED to an insurer or vision benefit manager after a previous disapproval of an application is one hundred eighty calendar days from the date of the previous application.

Q.Aninsurerorvisionbenefitmanagershallallowaneyecareprovider to become a participating provider in the network of a health benefit plan, vision benefit plan, or vision benefit discount plan if theeye careprovider does all of the following:

(1)Meetsthecredentialingrequirementsof theinsurerorvisionbenefit manager.

(2) Agrees in writing to the applicable provider agreement.

R.Aninsurerorvisionbenefitmanagershallallowalleyecareproviders who practice under a single Employer Identification Number or Tax Identification Number to become participating providers in the network of a healthbenefitplan,visionbenefitplan,orvisionbenefitdiscountplanifoneeye care provider practicing in that practice does all of the following:

(1)Meetsthecredentialingrequirementsof theinsurerorvisionbenefit manager.

(2) Agrees in writing to the applicable provider agreement.

S.

An insurer or vision benefit manager shall not exclude an eye care providerfromapplying toorbecomingaparticipatingproviderinthenetwork of a health benefit plan, vision benefit plan, or vision benefit discount plan because of any of the following:

(1) The aggregate number of eye care providers in a state, county, city, zip code, or other geographically defined service area.

(2) The time, distance, or appointment availability for an enrollee to access a participating eye care provider.

(3) The eye care provider's professional designation, independent practice affiliation, or participation status in other health benefit plans, vision benefit plans, or vision benefit discount plans.

T.

An insurer or vision benefit manager shall not deny participation to Page 20 of 33 Coding:

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404 ENROLLED anyeyecareprovideremployed byorunder contractwithafederallyqualified health center or rural health clinic, based on the practice setting, ownership structure, participation through the federally qualified health center or rural healthclinic,ordesignationasafederallyqualifiedhealthcenterorruralhealth clinic.

§1809.9.

Transparency and disclosure requirements for insurers and vision benefit managers A.Aninsurerorvisionbenefitmanagershalldiscloseallofthefollowing information publicly on its internet website and with all documents and document packages, including but not limited to proposals, responses to requests for proposals, sales documents, enrollment documents, benefit plan documents, purchaser contracts, enrollee contracts, and provider agreements that are presented to purchasers, potential purchasers, enrollees, potential enrollees, participating eye care providers, potential participating providers, andstateagencieswithjurisdictional,regulatory,orenforcementauthorityover its business:

(1) Its legal name and entity type.

(2) Its legal address and state in which the legal entity is formed or organized.

(3) The physical address, mailing address, electronic mail address, and phone number of its operational headquarters.

(4) The agencies, departments, committees, commissions, and other bodies that have jurisdictional, regulatory, or enforcement authority over the business.

(5) A statement that no jurisdictional, regulatory, or enforcement authority exists over its business, if none exists.

(6) The names, physical addresses, mailing addresses, electronic mail addresses, and phone numbers of all parent companies, related holding companies,wholly-ownedsubsidiarycompanies,andpartially-ownedsubsidiary companies.

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404 ENROLLED (7) All federal and state litigation in which the company is, or has been, a party to in the current year and during the preceding five years.

(8)AllDepartmentofInsuranceformalcomplaintsagainstthecompany inthecurrentyearandduringtheprecedingfiveyearsbypurchasers,enrollees, or eye care providers.

B.

All information required to be disclosed by an insurer or vision benefit manager in Subsection A of this Section shall be conveyed in plain language and typed with a minimum of ten point font size and prominently displayed in all of the following:

(1) On the insurer's or vision benefit manager's website in a publicly accessible section titled "Required Transparency Information for Patients, Doctors, and Purchasers".

(2) In a separately created document titled "Required Transparency Information forPatients,Doctors,and Purchasers"thatshall beincluded with all documents and document packages, including but not limited to proposals, responses to requests for proposals, benefit plan documents, sales documents, enrollment documents, purchaser contracts, enrollee contracts, and provider agreements.

C.

An insurer or vision benefit manager shall provide notice to each participating eye care provider of any proposed amendments to existing provideragreements,feeschedules,providerhandbooks, providermanuals,or related policy documents via electronic mail.

D.

A participating eye care provider shall be provided with a minimum of ninety calendar days from the time of distribution to review changes and respond, if necessary, to any proposed amendments from an insurer or vision benefit manager to existing provider agreements, fee schedules, provider handbooks,providermanuals,orrelatedpolicydocuments.Anysuchproposed amendments proffered by the insurer or vision benefit manager in violation of the foregoing shall be void and unenforceable.

E.

Any proposed amendments to existing provider agreements, fee Page 22 of 33 Coding:

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404 ENROLLED schedules,providerhandbooks,providermanuals,orrelatedpolicydocuments by an insurer or vision benefit manager delivered to a participating eye care provider shall be all of the following:

(1) Enumerated in a cover letter.

(2) Marked with highlights or as tracked changes within the applicable agreementsordocuments,toclearlydisplayallchangesoveranyoftheprevious version.

(3)Structuredtoincludeimplicationsofagreementornonagreementby the participating eye care provider.

F.

An insurer or vision benefit manager shall maintain all of the following:

(1) A phone number for company representatives to receive questions and communications from participating eye care providers at all times during standard business hours.

(2) The ability for an eye care provider to leave voice messages at all times.

(3) The ability for an eye care provider to have a live phone discussion withacompanyrepresentativewithintwenty-fourhoursofaninitialphonecall or a voice message left with the insurer or vision benefit manager.

G.

An insurer or vision benefit manager shall maintain a physical mailing address and an electronic mail address to company representatives to receive questions, disputes, and communications from participating eye care providers about all matters, at all times, including but not limited to proposed amendments to existing provider agreements, fee schedules, provider handbooks, provider manuals, and related policy documents, and will publish instructions for mail submission and electronic mail submission of questions, disputes, and communications in a place visible to participating eye care providers including on its website and in any provider agreements, provider handbooks, provider manuals, or related policy documents.

H.Aninsurerorvisionbenefitmanagershallacknowledgereceiptofan Page 23 of 33 Coding:

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404 ENROLLED electronic mail message within one hour by use of a return electronic mail message with a communication tracking number and shall respond to the substantive questions or communications of theelectronicmail messagewithin seventy-two hours in writing by use of a return electronic mail message.

I.Aninsurerorvisionbenefitmanagershall,atalltimes,makeavailable totheeyecareproviderthemostup-to-dateprovideragreements,feeschedules, provider handbooks, provider manuals, and related policy documents via website access.

J.

Insurers or vision benefit managers shall not engage in marketing or advertising activities that are misleading or deceptive to the public.

Such acts are considered an unfair practice or act in accordance with the Unfair Trade Practices and Consumer Protection Law, R.S.

51:1401 et seq.

K.

Upon request by a state agency with jurisdictional, regulatory, or enforcement authority over its business, insurers and vision benefit managers shallsubmitallinformationrelatedtoahealthbenefitplan,visionbenefitplan, orvisionbenefitdiscountplan,includingbutnotlimitedtoproposals,responses torequestsforproposals,benefitplan documents,salesdocuments,enrollment documents, purchaser contracts, enrollee contracts, provider agreements, and marketing and advertising activities for review.

§1809.10.

Amending agreements;

contracts;

payment methods;

security interests;

arbitration expenses A.

An insurer or vision benefit manager shall not change or alter a contract or agreement, including terms, reimbursements, or fee schedules, entered into with a participating eye care provider unless the insurer or vision benefit manager complies with all of the following requirements at least ninety days before the date of the proposed change would take effect:

(1) A certified letter, or an electronic communication requiring an electronic signature proving receipt, detailing proposed changes is required to be sent to the eye care provider.

(2) A face-to-face or virtual meeting is required to discuss proposed Page 24 of 33 Coding:

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404 ENROLLED changes, if requested by the eye care provider.

(3) The eye care provider shall either agree or not agree in writing to proposed changes.

If the changes in the contract or agreement are not agreed to by the eye care provider then the current agreement shall continue and the insurer or vision benefit manager may not remove the eye care provider from a network panel or plan for not accepting the proposed changes to a contract or agreement.

(4)Anewagreementisrequiredtobeestablished andagreeduponafter threeor more material changes, are made to an existing agreement between an eye care provider and an insurer or vision benefit manager.

(5)Anyproposedamendmenttoan existing contractoragreementshall bepresentedtotheparticipatingeyecareproviderinamannerconducivetothe provider's review.

Proposed changes will be enumerated in a cover letter and clearly marked as tracked changes within the body of the applicable contract or agreement.

B.Acontractoragreementbetweenaninsurerorvisionbenefitmanager and an eye care provider shall not contain any provision requiring an optometrist to accept a reimbursement payment in the form of a virtual credit cardoranyotherpaymentmethodwhereinaprocessingfee,administrativefee, percentageamount, ordollar amount is assessedforthe provider toreceivethe reimbursement payment.

C.

Termination of any contract or agreement shall be permissible only in theevent of a material breach, wherein the eye careprovider fails to remedy theallegedbreach to the reasonable satisfactionof theinsurerorvision benefit manager within thirty days of receipt of written notice specifying the alleged breach.

D.

It shall be prohibited for an insurer or vision benefit manager to requireaneyecareprovidertoestablishasecurityinterestinallorpartoftheir property and assets, including assets pertaining to their practice, in a sum equivalent to the funds owed to the insurer or vision benefit manager at Page 25 of 33 Coding:

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404 ENROLLED termination.

Any such contractual language, policies, or procedures set by the insurerorvisionbenefitmanagerinviolationoftheforegoingshallbevoidand unenforceable.

E.Acontractoragreementbetweenaninsurerorvisionbenefitmanager and an eye care provider shall not contain a provision obligating the eye care provider to equally share the expenses of arbitration.

Each party shall bear theirownarbitrationcosts,contingentuponafee-shiftingprovisionthatgrants prevailing party status.

F.Aninsurerorvisionbenefitmanagershallnotretaliateinanymanner against an eye care provider for discussing, or attempting in good faith to negotiate,thetermsand provisionsofaprovideragreementwiththeinsureror vision benefit manager.

G.Aninsurerorvisionbenefitmanagershallnotretaliateinanymanner against an eyecareprovider for filing a complaint against the insurer or vision benefit manager with any state agency with jurisdictional, regulatory, or enforcement authority over the business of the insurer or vision benefit manager.

H.

Should retaliation by an insurer or vision benefit manager occur against an eye care provider in violation of Subsections F or G of this Section, thecommissionermaysanctiontheinsurerorvisionbenefitmanager,including fines and other remedies deemed appropriate, and provide an appropriate remedy for the aggrieved eye care provider.

§1809.11.

Optical labs and suppliers A.

No contract or agreement between an insurer or vision benefit manager and an eye care provider shall restrict or limit, either directly or indirectly, the eye care provider's choice or use of sources and suppliers of covered or uncovered services or materials, including the choice or use of optical laboratories,providedbytheeyecareprovidertoanenrollee.Anysuch contractuallanguage,policies,orproceduressetbytheinsurerorvisionbenefit manager in violation of the foregoing shall be void and unenforceable.

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404 ENROLLED B.

An insurer or vision benefit manager shall not directly or indirectly do any of the following:

(1) Control or attempt to control the professional judgment, manner of practice, or practice of an eye care provider.

(2)Employ an eye careprovidertoprovide acoveredserviceorcovered material.

(3) Withhold or recoup payment to an eye care provider for covered servicesorcoveredmaterialsprovidedforanenrolleeiftheenrolleewasshown to be eligible on the date that the covered services or covered materials were provided.

(4) Reimburse an eye care provider a different amount for covered services or covered materials because of the eye care provider's choice of any of the following:

(a) Optical laboratory.

(b) Source of supplier of any of the following:

(i) Contact lenses.

(ii) Ophthalmic lenses.

(iii) Ophthalmic glasses frames.

(iv) Covered or non-covered services or materials.

(c) Equipment used for patient care.

(d) Retail optical affiliation.

(e) Vision support organization.

(f) Group purchasing organization.

(g) Doctor alliance or group.

(h) Professional trade association membership.

(i)Electronichealthrecordsoftware,electronicmedicalrecordsoftware, or practice management software.

(j) Third-party claim filing service, billing service, or electronic data interchange clearinghouse company.

(5) Restrict, limit, or influence an eye care provider's choice of sources Page 27 of 33 Coding:

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404 ENROLLED or suppliers of services or materials, including optical laboratories used by the eye care provider to provide services or materials to the enrollee.

(6)Restrict,limit,orinfluenceaneyecareprovider'schoiceofelectronic health record software, electronic medical record software, or practice management software.

(7) Restrict, limit, or influence an eye care provider's choice of third-party claim filing service, billing service, or electronic data interchange clearinghouse company.

(8) Restrict or limit an eye care provider's access to an enrollee's completeplancoverageinformation,including in-networkandout-of-network coverage details.

(9) Apply a chargeback to an enrollee or eye care provider if the chargeback is for a covered product or service for which the insurer or vision benefit manager does not incur the cost to produce, deliver, or provide to the enrollee or eye care provider.

(10) Require an eye care provider to disclose an enrollee's confidential orprotectedhealthinformationunlessthedisclosureisexpresslyauthorizedby the enrollee, or permitted without authorization under the Health Insurance Portability and Accountability Act of 1996.

(11)Requireaneyecareprovidertodisclose orreportamedicalhistory or diagnosis as a condition to file a claim, adjudicate a claim, or receive reimbursement for a routine or wellness eye exam.

(12) Require an eye care provider to disclose or report an enrollee's glasses prescription, contact lens prescription, ophthalmic device measurements, facial photograph, or unique anatomical measurements as condition to file a claim, adjudicate a claim, or receive reimbursement for a claim, unless the information is needed for the vision benefit manager to manufacture,orcausetobemanufactured,acoveredproductthatissubmitted on the applicable claim.

(13) Require an eye care provider to disclose any enrollee information, Page 28 of 33 Coding:

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404 ENROLLED otherthan information identified on theversionoftheHealthInsuranceClaim FormapprovedbytheNationalUniformClaimCommitteeasofMarch1,2023, or its approved successor, as a condition to file a claim, adjudicate a claim, or receive reimbursement for a claim unless the information is needed for the visionbenefitmanagertomanufacture,orcausetobemanufactured,acovered product that is submitted on the applicable claim.

C.

An insurer or vision benefit manager shall not solicit patients or referrals for supplies on behalf of itself or its affiliates by identifying participating eye care providers in an inaccurate or otherwise misleading manner, in any list of participating providers, or in any communications to purchasers or enrollees.

All communications which distinguish between participating eye care providers, or which otherwise claim professional superiority or the performance of a professional service in a superior manner, based on any of the following characteristics, shall be readily subject to verification by the Department of Insurance:

(1)Adiscountorincentiveofferedbytheparticipatingeyecareprovider on services and materials that are not covered by the insurer or vision benefit manager.

(2)The dollar amount, volume amount, or percentusage amount of any material, product, or good purchased by the participating eye care provider.

(3)Thebrand,source,manufacturer,orsupplierofacoveredserviceor covered material utilized by the participating eye care provider.

D.

This Section shall not prohibit advertising, provided that such advertising is not false, misleading, or deceptive and is readily subject to verification.

§1809.12.

Extrapolation prohibited A.

An insurer or vision benefit manager shall not use extrapolation to completeanauditofaparticipatingeyecareprovider.Anyadditionalpayment due to a participating eye care provider or any refund due to the insurer or vision benefit manager shall not be based on an extrapolation, but shall be Page 29 of 33 Coding:

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404 ENROLLED based on the actual overpayment or underpayment, as determined after an investigation by the insurer or vision benefit manager, and participating eye careproviderhasbeenafforded,andhasexhausted,allopportunitiestoappeal the insurer or vision benefit manager's findings, as set forth in the provider manual, policy document, or applicable law.

B.

For purposes of this Section, "extrapolation" means a mathematical formula, process, or technique used by a vision benefit manager, or the vision benefitmanager'sagent,in theaudit of an optometristtoestimateaudit results or findings for a larger batch or group of claims not reviewed by the vision benefit manager.

§1809.13.

Private right of action;

eye care providers Any eye careprovider adversely affectedby aviolation of this Part may bringanactionin a courtof competentjurisdictionforinjunctivereliefagainst the insurer or vision benefit manager and, upon prevailing, in addition to such injunctive relief, shall recover monetary damages, including but not limited to direct, indirect, special, and punitive damages and penalties, of no more than ten thousand dollars for each violation, plus attorney fees and costs.

§1809.14.

Relationship to other laws The requirements of this Part are in addition to, and do not limit, any other requirement applicable to an insurer under state law.

In the event of a conflict between this Part and another provision of law applicable to insurers, the provision that affords greater protection to eye care providers or plan enrollees shall control.

Notwithstanding any other provision of law, including any law that purports to be the sole body of law governing the insurer, an insurershall comply with this Part,to the extent not preempted byfederallaw.

§1809.15.

Authorization for enforcement A.

The Department of Insurance has jurisdiction to administer and enforce this Part with respect to any insurer or vision benefit manager.

The department may do any of the following:

(1)Bringanaction,issueorders,andimposeremediesauthorizedbythis Page 30 of 33 Coding:

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404 ENROLLED Part against any insurer or vision benefit manager.

(2) Adopt rules to identify activities that constitute the administration, management, or control of vision benefits or materials.

(3) Coordinate enforcement with other state agencies that regulate insurersunderotherapplicablelaw.Theattorneygeneralshallhaveconcurrent enforcement authority for violations constituting unfair or deceptive acts or practices.

B.

The Department of Insurance shall do all of the following:

(1) Provide a mechanism for aggrieved individuals, whether actively or formerlyenrolledwithaparticularvisioncareplan,tosubmitcomplaintstothe department for review, investigation, and as appropriate, discipline under applicable law.

(2) Enforce the state's insurance laws and the provisions of this Part using powers granted to the commissioner in this Title.

(3) Ensure that insurers and vision benefit managers comply with the requirements of this Part.

(4) Be entitled to seek an injunction against an insurer or vision benefit manager in a court of competent jurisdiction if the insurer or vision benefit manager does any of the following:

(a) Issues a coverage policy that does not comply with the requirements of this Part, uses fraudulent, coercive, or dishonest practices, or demonstrates incompetence,untrustworthiness,orfinancialirresponsibilityintheconductof business.

(b) Fails to deal equitably with any eye care provider or other persons or facilities which offer services or materials covered within an agreement or contractor policy issued pursuant to this Part.

(c) Fails to substantially comply with the insurance laws of this state or violates any regulation, rule, subpoena, or order of the commissioner.

C.

The attorney general shall do all of the following:

(1) Enforce the provisions of this Part concerning discount card plans, Page 31 of 33 Coding:

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404 ENROLLED using powers granted to the attorney general pursuant to this Title and the Unfair Trade Practices and Consumer Protection Law, R.S.

51:1401, et seq.

(2) Be entitled to seek an injunction against an insurer or vision benefit manager in a court of competent jurisdiction.

§1809.16.

Enactment provisions A.

The requirements of this Part shall apply to insurer or vision benefit manager policies, agreements, contracts, addenda, and certificates executed, delivered, issued for delivery, continued, or renewed in the state of Louisiana.

B.

No insurer or vision benefit manager agreement may be longer than two years from the date that it was signed by both parties.

C.

No insurer or vision benefit manager shall construe re-credentialing asre-contractingwithaparticipatingeyecareprovider.Aprovidercontractor agreement shall be a distinctly separate document from any credentialing materials and shall be signed by theeyecareproviderand theinsurer or vision benefit manager.

D.

An insurer or vision benefit manager shall include a copy of the current plan provider manual referred to in a provider contract or agreement at the time a contract or agreement is sent to any provider and prospective provider, as well as any policies referenced in the contract or agreement.

Section 2.

The provisions of this Act shall apply to all insurers and vision benefit managers upon the earlier of:

(A)Therenewalofenrollee'scurrentbenefitplanoruponissueofanewbenefitplan to any enrollee.

(B) The initiation of a new contract or agreement with an eye care provider or upon any modification of an existing contract or agreement with an eye care provider.

(C) January 1, 2027.

Section 3.