AN ACT Relating to the administration of vision benefits; reenacting and amending RCW 48.200.020 and 41.05.017; adding a new section to chapter 48.200 RCW; adding a new section to chapter 48.43 RCW; creating a new section; and providing an effective date.

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Affiliate" or "affiliated employer" means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, another specified person.

(4) "Employee benefits programs" means programs under both the public employees' benefits board established in RCW 41.05.055 and the school employees' benefits board established in RCW 41.05.740.

(5)(a) "Health care benefit manager" means a person or entity providing services to, or acting on behalf of, a health carrier or employee benefits programs, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies including, but not limited to:

(b) "Health care benefit manager" includes, but is not limited to, health care benefit managers that specialize in specific types of health care benefit management such as pharmacy benefit managers, radiology benefit managers, laboratory benefit managers, vision benefit managers, and mental health benefit managers.

(viii) An employer administering its employee benefit plan or the employee benefit plan of an affiliated employer under common management and control;

(ix) A union, either on its own or jointly with an employer, administering a benefit plan on behalf of its members;

(x) An insurance producer selling insurance or engaged in related activities within the scope of the producer's license;

(xi) A creditor acting on behalf of its debtors with respect to insurance, covering a debt between the creditor and its debtors;

(xii) A behavioral health administrative services organization or other county-managed entity that has been approved by the state health care authority to perform delegated functions on behalf of a carrier;

(xiii) A hospital licensed under chapter 70.41 RCW or ambulatory surgical facility licensed under chapter 70.230 RCW, to the extent that it performs provider credentialing or recredentialing, but no other functions of a health care benefit manager as described in (a) of this subsection (((5)(a) of this section [(a) of this subsection]));

(xvii) Any other entity that performs provider credentialing or recredentialing, but no other functions of a health care benefit manager as described in (a) of this subsection (((5)(a) of this section [(a) of this subsection])).

(9) "Laboratory benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of clinical laboratory services and includes any requirement for a health care provider to submit a notification of an order for such services.

(10) "Mail order pharmacy" means a pharmacy that primarily dispenses prescription drugs to patients through the mail or common carrier.

(11) "Mental health benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination of utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of mental health services and includes any requirement for a health care provider to submit a notification of an order for such services.

(12) "Network" means the group of participating providers, pharmacies, and suppliers providing health care services, drugs, or supplies to beneficiaries of a particular carrier or plan.

(13) "Person" includes, as applicable, natural persons, licensed health care providers, carriers, corporations, companies, trusts, unincorporated associations, and partnerships.

(14)(a) "Pharmacy benefit manager" means a person that contracts with pharmacies on behalf of a health carrier, employee benefits program, or medicaid managed care program to:

(i) Process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;

(iii) Negotiate rebates, discounts, or other price concessions with manufacturers for drugs paid for or procured as described in this subsection;

(b) "Pharmacy benefit manager" does not include a health care service contractor as defined in RCW 48.44.010.

(15) "Pharmacy network" means the pharmacies located in the state or licensed under chapter 18.64 RCW and contracted by a pharmacy benefit manager to dispense prescription drugs to covered persons.

(16)(a) "Radiology benefit manager" means any person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, the services of a licensed radiologist or to advanced diagnostic imaging services including, but not limited to:

(i) Processing claims for services and procedures performed by a licensed radiologist or advanced diagnostic imaging service provider; or

(ii) Providing payment or payment authorization to radiology clinics, radiologists, or advanced diagnostic imaging service providers for services or procedures.

(b) "Radiology benefit manager" does not include a health care service contractor as defined in RCW 48.44.010, a health maintenance organization as defined in RCW 48.46.020, or an issuer as defined in RCW 48.01.053.

(18) "Vision benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination of utilization of benefits for, or patient access to, health care services, materials, drugs, and supplies relating to the use of vision services or vision materials.

(19) "Vision materials" means ophthalmic devices including, but not limited to, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens mounting apparatuses, prisms, lens treatments and coatings, contact lenses, or prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.

(a) Provide different reimbursement amounts for covered vision services or covered vision materials among tiers of contracting providers of the same licensed profession in the same health plan;

(b) Reimburse a provider licensed under chapter 18.53 RCW, acting within the provider's scope of practice, less than it reimburses ophthalmologists licensed under chapter 18.57 or 18.71 RCW for the same covered vision services or covered vision materials;

(c) Require a contracting provider to purchase vision services or vision materials from suppliers, including optical laboratories, in which the vision benefit manager has a financial interest;

(d) Require a contracting provider to provide vision services or vision materials at a fee limited or set by the vision benefit manager, unless the vision materials or services are covered vision services or covered vision materials;

(e) Require a provider of covered vision services or covered vision materials, as a condition of becoming a participating provider for a specific health plan, to:

(i) Join a network of providers maintained by the vision benefit manager in lieu of contracting directly with the health carrier;

(ii) Participate with any other health plan, including another health plan managed by, or affiliated with, the vision benefit manager; or

(f) Require an enrollee's cost sharing, including copayments, for covered vision services or vision materials to exceed 50 percent of the amount the provider is reimbursed for those services or materials, unless a higher amount is necessary to preserve the enrollee's ability to claim tax exempt contributions from the enrollee's health savings account under internal revenue service laws and regulations; or

(g) Impose different credentialing standards for providers licensed under chapter 18.53 RCW than it imposes for ophthalmologists licensed under chapter 18.57 or 18.71 RCW.

(c) Vision-only coverage issued by a limited health care service contractor under chapter 48.44 RCW or a health carrier as defined in chapter 48.43 RCW.

(3) This section applies to contracts entered into or renewed on or after the effective date of this section.

(1) A health carrier offering vision coverage or a limited health care service contractor offering vision-only coverage may not:

(a) Provide different reimbursement amounts for covered vision services or covered vision materials among tiers of contracting providers of the same licensed profession in the same health plan;

(c) Require a contracting provider to purchase vision services or vision materials from suppliers, including optical laboratories, in which the health carrier, limited health care service contractor, or affiliated vision benefit manager has a financial interest;

(d) Require a contracting provider to provide vision services or materials at a fee limited or set by the health carrier, limited health care service contractor, or affiliated vision benefit manager, unless the vision services or vision materials are covered vision services or covered vision materials;

(e) Require a provider of covered vision services or covered vision materials, as a condition of becoming a participating provider for a specific health plan, to:

(i) Join a network of providers maintained by a vision benefit manager in lieu of contracting directly with the health carrier;

(ii) Participate with any other health plan, including another health plan managed by, or affiliated with, an affiliated vision benefit manager; or

(g) Impose different credentialing standards for providers licensed under chapter 18.53 RCW than it imposes for ophthalmologists licensed under chapter 18.57 or 18.71 RCW.

(ii) Vision-only coverage issued by a limited health care service contractor under chapter 48.44 RCW or a health carrier.

(d) "Vision materials" means ophthalmic devices including, but not limited to, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens mounting apparatuses, prisms, lens treatments and coatings, contact lenses, or prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa.

(3) This section applies to contracts entered into or renewed on or after the effective date of this section.

Sec. 4. RCW 41.05.017 and 2024 c 251 s 5 and 2024 c 242 s 10 are each reenacted and amended to read as follows:

Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, section 3 of this act, and chapter 48.49 RCW.