Medicaid Direct Access for Optometrists (SB 10)

The following is an excerpt from SB 10 regarding direct access to optometrists in the Medicaid program:

05-28-2007

 1      SECTION 21. (a) Subchapter B, Chapter 32, Human Resources
 2 Code, is amended by adding Section 32.072 to read as follows:
 3      Sec. 32.072. DIRECT ACCESS TO EYE HEALTH CARE SERVICES.
 4 (a) Notwithstanding any other law, a recipient of medical
 5 assistance is entitled to:
 6           (1) select an ophthalmologist or therapeutic
 7 optometrist who is a medical assistance provider to provide eye
 8 health care services, other than surgery, that are within the scope
 9 of:
10                (A) services provided under the medical
11 assistance program; and
12                (B) the professional specialty practice for
13 which the ophthalmologist or therapeutic optometrist is licensed
14 and credentialed; and
15           (2) have direct access to the selected ophthalmologist
16 or therapeutic optometrist for the provision of the nonsurgical
17 services without any requirement to obtain:
18                (A) a referral from a primary care physician or
19 other gatekeeper or health care coordinator; or
20                (B) any other prior authorization or
21 precertification.
22           (b) The department may require an ophthalmologist or
23 therapeutic optometrist selected as provided by this section by a
24 recipient of medical assistance who is otherwise required to have a
25 primary care physician or other gatekeeper or health care
26 coordinator to forward to the recipient's physician, gatekeeper, or
27 health care coordinator information concerning the eye health care
28 services provided to the recipient.
29           (c) This section may not be construed to expand the scope of
30 eye health care services provided under the medical assistance
31 program.
32           (b) Subchapter A, Chapter 533, Government Code, is amended
33 by adding Section 533.0026 to read as follows:
34           Sec. 533.0026. DIRECT ACCESS TO EYE HEALTH CARE SERVICES
35 UNDER MEDICAID MANAGED CARE MODEL OR ARRANGEMENT.
36 (a) Notwithstanding any other law, the commission shall ensure
37 that a managed care plan offered by a managed care organization that
38 contracts with the commission under this chapter and any other
39 Medicaid managed care model or arrangement implemented under this
40 chapter allow a Medicaid recipient who receives services through
41 the plan or other model or arrangement to, in the manner and to the
42 extent required by Section 32.072, Human Resources Code:
43           (1) select an in-network ophthalmologist or
44 therapeutic optometrist in the managed care network to provide eye
45 health care services, other than surgery; and
46           (2) have direct access to the selected in-network
47 ophthalmologist or therapeutic optometrist for the provision of the
48 nonsurgical services.
49           (b) This section does not affect the obligation of an
50 ophthalmologist or therapeutic optometrist in a managed care
51 network to comply with the terms and conditions of the managed care
52 plan.
53           (c) The changes in law made by Section 533.0026, Government
54 Code, as added by this section, apply to a contract between the
55 Health and Human Services Commission and a managed care
56 organization under Chapter 533, Government Code, that is entered
57 into or renewed on or after the effective date of this section.