Vision Care Plan Regulation Act FAQs

SB 764
Vision Care Plan Regulation Act

Frequently Asked Questions 

1. When will this act become effective?
a. SB 764 was signed by Governor Pritzker on August 4th, 2023, and is effective immediately. However, you will not see changes to your contract until the terms of the contract are amended, delivered, issued, or renewed. At that time, the contract shall comply with the provisions of the act.

2. Who enforces this act?
a. The Illinois Department of Insurance.

3. How can I file a complaint against a vision plan?
a. Click here: https://idoihelpcenter.illinois.gov/s/

4. How does this act impact non-covered services?
a. No plan shall issue a contract that requires as a condition of participation to provide services or materials to an enrollee at a fee set by the plan unless the services or materials are covered services or covered materials under the plan.

5. What happens if I choose not to accept the payment amount set by the plan for services or materials that are not covered services or covered materials?
a. The provider shall post, in a conspicuous place a notice stating the following:

“IMPORTANT: This eye care provider does not accept the fee schedule set by your insurer for vision care services and materials that are not covered benefits under your plan and instead charges his or her normal fee for those services and materials. This eye care provider will provide you with an estimated cost for each noncovered service or noncovered material upon your request.

6. What will the fees for covered services or covered materials be?
a. Fees paid under the plan for covered services or covered materials, regardless of the supplier or optical lab used to obtain materials, shall be reasonable and shall be clearly listed on a fee schedule that has been provided to the eye care provider before entering into a contract with the plan.
b. Please note, that fees paid for materials supplied by a non-network lab are not required to be identical to fees paid for materials ordered through a network lab, but non-network lab fees shall be reasonable.

7. Will this act apply to Medicaid and Medicare?
a. No, this act only applies to private vision care plans.

8. Can a vision care organization restrict or limit my choice of suppliers of services or covered materials?
a. No.
b. They cannot require you or the patient to purchase covered materials, including, but not limited to, ophthalmic lenses, from any source owned by, controlled by, or in a common ownership scheme with the entity that issues the vision care plan.
c. Please note if requested by an enrollee, an eye care provider recommending out-of-network sources of supplier of vision care materials shall provide written notice to the enrollee stating the following:

i. Source of supplier is an out-of-network lab or supplier of vision care materials, and
ii. Any business interest that the eye care provider has in the out-of-network source of supplier recommended to the enrollee. An example of a “business interest” may be the receipt of rebates from an out of network source. A “business interest” includes an ownership interest in an out of network source.
iii. You are required to offer an enrollee in-network sources or suppliers of vision care materials at the enrollees’ request.

9. When can a vision plan change the terms, fees, discounts, or reimbursement rates in the plan?
a. A vision care plan may not change the terms, fees, discounts, or reimbursement rates unless it is mutually agreed to in writing by the eye care provider and the vision care organization that issues the vision care plan.
b. Please note: a change proposed to a vision care plan by the vision care organization will become effective if the eye care provider fails to respond to the vision care organization within 60 days of receipt of notice of the proposed changes.

10. Any contract that is issued, delivered, amended, or renewed after the effective date of this act may not issue a contract that requires the following:
a. Require an eyecare provider to contract with a plan that offers supplemental or specialty health care services as a condition of contracting with a plan that offers basic health care.
b. Require an eyecare provider to contract with a plan as a condition to participate in a medical plan or in-network.

11. A vision care plan can do the following with a contract that is issued, delivered, amended, or renewed after the effective date of this act:
a. Enter into an agreement with a health care plan to deliver routine vision care services that are covered under the enrollee’s plan.
b. May act as a network regarding routine vision care services offered by a health care plan.

Important Definitions as implemented by SB 764:

"Covered materials" means materials for which reimbursement from the vision care plan 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 limitation of deductibles, copayments, or coinsurance. "Covered materials" includes lens treatment or coatings added to a spectacle lens if the base
 spectacle lens is a covered material. 

"Covered services" means services for which reimbursement from the vision care plan 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 plan limitation of deductibles, copayments, or coinsurance regardless of how the benefits are listed in an enrollee's benefit plan's definition of benefits.

"Enrollee" means any individual enrolled in a vision care plan provided by a group, employer, or other entity that purchases or supplies coverage for a vision care plan.

"Eye care provider" means a doctor of optometry licensed pursuant to the Illinois Optometric Practice Act of 1987 or a physician licensed to practice medicine in all of its branches pursuant to the Medical Practice Act of 1987.

"Materials" means ophthalmic devices, including, but not limited to:
(i) lenses, devices containing lenses, ophthalmic frames, and other lens mounting apparatus, prisms, lens treatments, and coatings;
(ii) contact lenses and prosthetic devices that correct, relieve, or treat defects or abnormal conditions of the human eye or adnexa; and 
(iii) any devices that deliver medication or other therapeutic treatment to the human eye or adnexa. 

"Services" means the professional work performed by an eye care provider.

"Subcontractor" means any company, group, or third-party entity, including agents, servants, partially-owned or wholly-owned subsidiaries and controlled organizations, that the vision care plan contracts with to supply services or materials for an eye care provider or enrollee to fulfill the benefit plan of a vision care plan. 

"Vision care organization" means an entity formed under the laws of this State or another state that issues a vision care plan. "Vision care plan" means a plan that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone plan that provides coverage for covered services and covered materials

This document is confidential and is provided to IOA members as a member benefit. 

Report Vision Plan Abuses to the IOA:

The IOA recognizes that this legislation constitutes a significant stride forward for optometry. However, it doesn't signal the conclusion of our efforts to champion fair contracting with vision plans. In the next few years, our members will be renewing and amending their contracts to reflect the changes in the new law. Throughout this process, we will gain valuable insight directly from our members regarding instances of vision plan abuses.

If you encounter vision plan abuses, we ask that you fill out the  form below to report abuse. The IOA will collect this information to prevent further vision plan abuses on behalf of our members.