§ 4098e. Choice of providers for vision care and medical eye care services
(a) As used in this section:
(1) “Covered services” means services and materials for which reimbursement from a vision
care plan or other health insurance plan is provided by a member’s or subscriber’s
plan contract, or for which a reimbursement would be available but for application
of the deductible, co-payment, or coinsurance requirements under the member’s or subscriber’s
health insurance plan.
(2) “Health insurance plan” has the same meaning as in section 4011 of this chapter and
also includes vision care plans.
(3) “Materials” includes lenses, devices containing lenses, prisms, lens treatments and
coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects
or abnormal conditions of the human eye or its adnexa.
(4) “Ophthalmologist” means a physician licensed pursuant to 26 V.S.A. chapter 23 or an osteopathic physician licensed pursuant to 26 V.S.A. chapter 33 who has had special training in the field of ophthalmology.
(5) “Optician” means a person licensed pursuant to 26 V.S.A. chapter 47.
(6) “Optometrist” means a person licensed pursuant to 26 V.S.A. chapter 30.
(7) “Vision care plan” means an integrated or stand-alone plan, policy, or contract providing
vision benefits to enrollees with respect to covered services or covered materials,
or both.
(b) To the extent a health insurance plan provides coverage for vision care or medical
eye care services, it shall cover those services whether provided by a licensed optometrist
or by a licensed ophthalmologist, provided the health care professional is acting
within the health care professional’s authorized scope of practice and participates
in the plan’s network.
(c) A health insurance plan shall impose no greater co-payment, coinsurance, or other
cost-sharing amount for services when provided by an optometrist than for the same
service when provided by an ophthalmologist.
(d) A health insurance plan shall provide to a licensed health care professional acting
within the health care professional’s scope of practice the same level of reimbursement
or other compensation for providing vision care and medical eye care services that
are within the lawful scope of practice of the professions of medicine, optometry,
and osteopathy, regardless of whether the health care professional is an optometrist
or an ophthalmologist.
(e)(1) A health insurer shall permit a licensed optometrist to participate in plans or contracts
providing for vision care or medical eye care to the same extent as it does an ophthalmologist.
(2) A health insurer shall not require a licensed optometrist or ophthalmologist to provide
discounted materials benefits or to participate as a provider in another health insurance
or vision care plan or contract as a condition or requirement for the optometrist’s
or ophthalmologist’s participation as a provider in any health insurance or vision
care plan or contract.
(f)(1) An agreement between a health insurer and an optometrist or ophthalmologist for the
provision of vision services to plan members or subscribers in connection with coverage
under a stand-alone vision care plan or other health insurance plan shall not require
that an optometrist or ophthalmologist provide services or materials at a fee limited
or set by the plan or insurer unless the services or materials are reimbursed as covered
services under the contract.
(2) An optometrist or ophthalmologist shall not charge more for services and materials
that are noncovered services under a vision care plan or other health insurance plan
than the optometrist’s or ophthalmologist’s usual and customary rate for those services
and materials.
(3) Reimbursement paid by a vision care plan or other health insurance plan for covered
services and materials shall be reasonable and shall not provide nominal reimbursement
in order to claim that services and materials are covered services.
(4)(A) A vision care plan or other health insurance plan shall not restrict or otherwise
limit, directly or indirectly, an optometrist’s, ophthalmologist’s, or independent
optician’s choice of or relationship with sources and suppliers of products, services,
or materials or use of optical laboratories if the optometrist, ophthalmologist, or
optician determines that the source, supplier, or laboratory that the optometrist,
ophthalmologist, or optician has selected offers the products, services, or materials
in a manner that is more beneficial to the consumer, including with respect to cost,
quality, timing, or selection, than the source, supplier, or laboratory selected by
the vision care plan or other health insurance plan. The plan shall not impose any
penalty or fee on an optometrist, ophthalmologist, or independent optician for using
any supplier, optical laboratory, product, service, or material.
(B) The optometrist, ophthalmologist, or optician shall notify the consumer of any additional
costs the consumer may incur as the result of procuring the products, services, or
materials from the source, supplier, or laboratory selected by the optometrist, ophthalmologist,
or optician instead of from the source, supplier, or laboratory selected by the vision
care plan or other health insurance plan.
(C) Nothing in this subdivision (4) shall be construed to prevent a vision care plan or
other health insurance plan from informing its policyholders of the benefits available
under the plan or from conducting an audit of an optometrist’s, ophthalmologist’s,
or optician’s use of alternative sources, suppliers, or laboratories.
(D) The provisions of this subdivision (4) shall not apply to Medicaid.
(g)(1) Except as otherwise specified in subdivision (f)(4), this section shall apply to Medicaid
and any other public health care assistance program offered or administered by the
State or by any subdivision or instrumentality of the State.
(2) The Department of Financial Regulation shall enforce the provisions of this section
as they relate to health insurance plans and vision care plans other than Medicaid. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)