{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.19.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.19.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.19.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.19.html"}],"law_id":83502,"edition_id":1,"section_id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","history":"2015, c. 723.","full_text":"A\n\nAs used in this section, unless the context requires a different meaning:\n\t\t\t&#8220;Covered materials&#8221; means lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, and devices to correct, relieve, or treat defects or abnormal conditions of the human eye and its adnexa for which benefits under a policy, contract, or evidence of coverage are payable by a vision care plan carrier, including materials paid by the insureds, subscribers, or enrollees because the annual or periodic payment maximum established by the vision care plan has been met.\n\t\t\t&#8220;Covered services&#8221; means the health care services for which benefits under a policy, contract, or evidence of coverage are payable by a vision care plan carrier, including services paid by the insureds, subscribers, or enrollees because the annual or periodic payment maximum established by the vision care plan has been met.\n\t\t\t&#8220;Enrollee&#8221; means any person entitled to health care services under a vision care plan.\n\t\t\t&#8220;Optometric services plan&#8221; has the same meaning ascribed thereto in &#xA7; 38.2-4501.\n\t\t\t&#8220;Participating provider agreement&#8221; means a contract or agreement between an optometrist or ophthalmologist and a vision care plan carrier in which the optometrist or ophthalmologist has agreed to provide vision-related health care services to enrollees and to hold those enrollees harmless from payment with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from a vision care plan.\n\t\t\t&#8220;Vision care plan&#8221; means (i) an individual or group accident and sickness insurance policy providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) an individual or group accident and sickness subscription contract; (iii) an optometric services plan; (iv) a health care plan provided by a health maintenance organization; or (v) an integrated or stand-alone vision benefit plan or a vision care insurance policy or contract that provides vision benefits to an enrollee pertaining to the provision of covered services or covered materials, under which policy, contract, or plan an enrollee is eligible to receive a benefit for covered services or covered materials.\n\t\t\t&#8220;Vision care plan carrier&#8221; means (i) an insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) a nonstock corporation providing individual or group accident and sickness subscription contracts; (iii) a nonstock corporation offering an optometric services plan; (iv) a health maintenance organization providing a health care plan; and (v) an entity that creates, promotes, sells, provides, advertises, or administers (a) an integrated or stand-alone vision benefit plan or (b) a vision care insurance policy or contract that provides vision benefits to an enrollee pertaining to the provision of covered services or covered materials.B\n\nNo participating provider agreement shall establish the fee or rate that the optometrist or ophthalmologist is required to accept for the provision of health care materials or services, or require that an optometrist or ophthalmologist accept the reimbursement paid as payment in full, unless the health care materials and services are covered materials or covered services under the applicable vision care plan.C\n\nReimbursement paid by the vision care plan carrier for covered services and covered materials shall be reasonable and shall not provide nominal reimbursement in order to claim that services and materials are covered services or covered materials under the applicable vision care plan. For the purposes of this subsection, &#8220;reasonable&#8221; means the negotiated fee or rate that is set forth in the participating provider agreement and is acceptable to the provider.D\n\nNo vision care plan shall require an optometrist or ophthalmologist to use a particular optical laboratory, manufacturer of eyeglass frames or contact lenses, or third-party supplier as a condition of participation in a vision care plan.E\n\nAny changes to a participating provider agreement proposed by the vision care plan carrier shall be submitted in writing to the optometrist or ophthalmologist at least 30 days prior to the effective date of such proposed changes.F\n\nThis section shall apply with respect to any participating provider agreement that is entered into, amended, extended, or renewed on or after January 1, 2016.G\n\nThe Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.H\n\nThe provisions of subsections B through G, as related to covered materials only, shall be applicable to licensed opticians practicing in the Commonwealth.","order_by":null,"text":{"0":{"id":299219,"text":"As used in this section, unless the context requires a different meaning:\n\t\t\t&#8220;Covered materials&#8221; means lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, and devices to correct, relieve, or treat defects or abnormal conditions of the human eye and its adnexa for which benefits under a policy, contract, or evidence of coverage are payable by a vision care plan carrier, including materials paid by the insureds, subscribers, or enrollees because the annual or periodic payment maximum established by the vision care plan has been met.\n\t\t\t&#8220;Covered services&#8221; means the health care services for which benefits under a policy, contract, or evidence of coverage are payable by a vision care plan carrier, including services paid by the insureds, subscribers, or enrollees because the annual or periodic payment maximum established by the vision care plan has been met.\n\t\t\t&#8220;Enrollee&#8221; means any person entitled to health care services under a vision care plan.\n\t\t\t&#8220;Optometric services plan&#8221; has the same meaning ascribed thereto in &#xA7; 38.2-4501.\n\t\t\t&#8220;Participating provider agreement&#8221; means a contract or agreement between an optometrist or ophthalmologist and a vision care plan carrier in which the optometrist or ophthalmologist has agreed to provide vision-related health care services to enrollees and to hold those enrollees harmless from payment with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from a vision care plan.\n\t\t\t&#8220;Vision care plan&#8221; means (i) an individual or group accident and sickness insurance policy providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) an individual or group accident and sickness subscription contract; (iii) an optometric services plan; (iv) a health care plan provided by a health maintenance organization; or (v) an integrated or stand-alone vision benefit plan or a vision care insurance policy or contract that provides vision benefits to an enrollee pertaining to the provision of covered services or covered materials, under which policy, contract, or plan an enrollee is eligible to receive a benefit for covered services or covered materials.\n\t\t\t&#8220;Vision care plan carrier&#8221; means (i) an insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) a nonstock corporation providing individual or group accident and sickness subscription contracts; (iii) a nonstock corporation offering an optometric services plan; (iv) a health maintenance organization providing a health care plan; and (v) an entity that creates, promotes, sells, provides, advertises, or administers (a) an integrated or stand-alone vision benefit plan or (b) a vision care insurance policy or contract that provides vision benefits to an enrollee pertaining to the provision of covered services or covered materials.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":299220,"text":"No participating provider agreement shall establish the fee or rate that the optometrist or ophthalmologist is required to accept for the provision of health care materials or services, or require that an optometrist or ophthalmologist accept the reimbursement paid as payment in full, unless the health care materials and services are covered materials or covered services under the applicable vision care plan.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":299221,"text":"Reimbursement paid by the vision care plan carrier for covered services and covered materials shall be reasonable and shall not provide nominal reimbursement in order to claim that services and materials are covered services or covered materials under the applicable vision care plan. For the purposes of this subsection, &#8220;reasonable&#8221; means the negotiated fee or rate that is set forth in the participating provider agreement and is acceptable to the provider.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":299222,"text":"No vision care plan shall require an optometrist or ophthalmologist to use a particular optical laboratory, manufacturer of eyeglass frames or contact lenses, or third-party supplier as a condition of participation in a vision care plan.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":299223,"text":"Any changes to a participating provider agreement proposed by the vision care plan carrier shall be submitted in writing to the optometrist or ophthalmologist at least 30 days prior to the effective date of such proposed changes.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":299224,"text":"This section shall apply with respect to any participating provider agreement that is entered into, amended, extended, or renewed on or after January 1, 2016.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":299225,"text":"The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":299226,"text":"The provisions of subsections B through G, as related to covered materials only, shall be applicable to licensed opticians practicing in the Commonwealth.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; 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protected information","url":"\/38.2-3407.22\/","token":"38.2\/34\/1\/38.2-3407.22","metadata":false},{"id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","metadata":false},{"id":62583,"structure_id":12994,"section_number":"38.2-3407.3:1","catch_line":"Premium payment arrearages; order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},{"id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","metadata":false},{"id":72294,"structure_id":12994,"section_number":"38.2-3407.4:1","catch_line":"Repealed","url":"\/38.2-3407.4_1\/","token":"38.2\/34\/1\/38.2-3407.4_1","metadata":false},{"id":57129,"structure_id":12994,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","url":"\/38.2-3407.4_2\/","token":"38.2\/34\/1\/38.2-3407.4_2","metadata":false},{"id":62057,"structure_id":12994,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.5\/","token":"38.2\/34\/1\/38.2-3407.5","metadata":false},{"id":54072,"structure_id":12994,"section_number":"38.2-3407.5:1","catch_line":"Coverage for prescription contraceptives","url":"\/38.2-3407.5_1\/","token":"38.2\/34\/1\/38.2-3407.5_1","metadata":false},{"id":79611,"structure_id":12994,"section_number":"38.2-3407.5:2","catch_line":"Reimbursements for dispensing hormonal contraceptives","url":"\/38.2-3407.5_2\/","token":"38.2\/34\/1\/38.2-3407.5_2","metadata":false},{"id":83778,"structure_id":12994,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","url":"\/38.2-3407.6\/","token":"38.2\/34\/1\/38.2-3407.6","metadata":false},{"id":74649,"structure_id":12994,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.6_1\/","token":"38.2\/34\/1\/38.2-3407.6_1","metadata":false},{"id":72641,"structure_id":12994,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_section":{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},"next_section":{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.19\/","history_text":"<p>This law was first created in 2015. The record of its establishment is cataloged in chapter <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?151+ful+CHAP0723\">723<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":[{"id":62548,"section_number":"38.2-4509","catch_line":"Application of certain laws","order_by":null,"url":"\/38.2-4509\/"}],"refers_to":[{"id":78064,"section_number":"38.2-4501","catch_line":"Definitions","order_by":null,"url":"\/38.2-4501\/"}],"permalink":{"id":215051,"object_type":"law","relational_id":83502,"identifier":"38.2-3407.19","token":"38.2\/34\/1\/38.2-3407.19","url":"\/38.2-3407.19\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","dublin_core":{"Title":"Payment for services by optometrists and ophthalmologists","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.19","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t<section id=\"A\"><p><span class=\"prefix-number\">A.<\/span> As used in this section, unless the context requires a different meaning:\n\t\t\t&#8220;<span class=\"dictionary\">Covered materials<\/span>&#8221; means lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, and devices to correct, relieve, or treat defects or abnormal conditions of the human eye and its adnexa for which benefits under a policy, <span class=\"dictionary\">contract<\/span>, or <span class=\"dictionary\">evidence<\/span> of coverage are payable by a <span class=\"dictionary\"><span class=\"dictionary\">vision care plan<\/span> carrier<\/span>, including materials paid by the insureds, subscribers, or <span class=\"dictionary\">enrollees<\/span> because the annual or periodic payment maximum established by the <span class=\"dictionary\">vision care plan<\/span> has been met.\n\t\t\t&#8220;<span class=\"dictionary\">Covered services<\/span>&#8221; means the health care services for which benefits under a policy, <span class=\"dictionary\">contract<\/span>, or <span class=\"dictionary\">evidence<\/span> of coverage are payable by a <span class=\"dictionary\"><span class=\"dictionary\">vision care plan<\/span> carrier<\/span>, including services paid by the insureds, subscribers, or <span class=\"dictionary\">enrollees<\/span> because the annual or periodic payment maximum established by the <span class=\"dictionary\">vision care plan<\/span> has been met.\n\t\t\t&#8220;<span class=\"dictionary\">Enrollee<\/span>&#8221; means any <span class=\"dictionary\">person<\/span> entitled to health care services under a <span class=\"dictionary\">vision care plan<\/span>.\n\t\t\t&#8220;Optometric services plan&#8221; has the same meaning ascribed thereto in &#xA7; <a class=\"law\" title=\"Definitions\" href=\"\/38.2-4501\/\">38.2-4501<\/a>.\n\t\t\t&#8220;<span class=\"dictionary\">Participating provider agreement<\/span>&#8221; means a <span class=\"dictionary\">contract<\/span> or agreement between an optometrist or ophthalmologist and a <span class=\"dictionary\"><span class=\"dictionary\">vision care plan<\/span> carrier<\/span> in which the optometrist or ophthalmologist has agreed to provide vision-related health care services to <span class=\"dictionary\">enrollees<\/span> and to hold those <span class=\"dictionary\">enrollees<\/span> harmless from payment with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from a <span class=\"dictionary\">vision care plan<\/span>.\n\t\t\t&#8220;<span class=\"dictionary\">Vision care plan<\/span>&#8221; means (i) an individual or group accident and sickness insurance policy providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) an individual or group accident and sickness subscription <span class=\"dictionary\">contract<\/span>; (iii) an optometric services plan; (iv) a health care plan provided by a health maintenance organization; or (v) an integrated or stand-alone vision benefit plan or a vision care insurance policy or <span class=\"dictionary\">contract<\/span> that provides vision benefits to an <span class=\"dictionary\">enrollee<\/span> pertaining to the provision of <span class=\"dictionary\">covered services<\/span> or <span class=\"dictionary\">covered materials<\/span>, under which policy, <span class=\"dictionary\">contract<\/span>, or plan an <span class=\"dictionary\">enrollee<\/span> is eligible to receive a benefit for <span class=\"dictionary\">covered services<\/span> or <span class=\"dictionary\">covered materials<\/span>.\n\t\t\t&#8220;<span class=\"dictionary\"><span class=\"dictionary\">Vision care plan<\/span> carrier<\/span>&#8221; means (i) an <span class=\"dictionary\">insurer<\/span> proposing to <span class=\"dictionary\">issue<\/span> individual or group accident and sickness <span class=\"dictionary\">insurance policies<\/span> providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis; (ii) a nonstock corporation providing individual or group accident and sickness subscription <span class=\"dictionary\">contracts<\/span>; (iii) a nonstock corporation offering an optometric services plan; (iv) a health maintenance organization providing a health care plan; and (v) an entity that creates, promotes, sells, provides, advertises, or administers (a) an integrated or stand-alone vision benefit plan or (b) a vision care insurance policy or <span class=\"dictionary\">contract<\/span> that provides vision benefits to an <span class=\"dictionary\">enrollee<\/span> pertaining to the provision of <span class=\"dictionary\">covered services<\/span> or <span class=\"dictionary\">covered materials<\/span>. <a id=\"paragraph-299219\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#A\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"B\"><p><span class=\"prefix-number\">B.<\/span> No <span class=\"dictionary\">participating provider agreement<\/span> shall establish the fee or <span class=\"dictionary\">rate<\/span> that the optometrist or ophthalmologist is required to accept for the provision of health care materials or services, or require that an optometrist or ophthalmologist accept the reimbursement paid as payment in full, unless the health care materials and services are <span class=\"dictionary\">covered materials<\/span> or <span class=\"dictionary\">covered services<\/span> under the applicable <span class=\"dictionary\">vision care plan<\/span>. <a id=\"paragraph-299220\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#B\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"C\"><p><span class=\"prefix-number\">C.<\/span> Reimbursement paid by the <span class=\"dictionary\"><span class=\"dictionary\">vision care plan<\/span> carrier<\/span> for <span class=\"dictionary\">covered services<\/span> and <span class=\"dictionary\">covered materials<\/span> shall be <span class=\"dictionary\">reasonable<\/span> and shall not provide nominal reimbursement in <span class=\"dictionary\">order<\/span> to claim that services and materials are <span class=\"dictionary\">covered services<\/span> or <span class=\"dictionary\">covered materials<\/span> under the applicable <span class=\"dictionary\">vision care plan<\/span>. For the purposes of this subsection, &#8220;<span class=\"dictionary\">reasonable<\/span>&#8221; means the negotiated fee or <span class=\"dictionary\">rate<\/span> that is set forth in the <span class=\"dictionary\">participating provider agreement<\/span> and is acceptable to the provider. <a id=\"paragraph-299221\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#C\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"D\"><p><span class=\"prefix-number\">D.<\/span> No <span class=\"dictionary\">vision care plan<\/span> shall require an optometrist or ophthalmologist to use a particular optical laboratory, manufacturer of eyeglass frames or contact lenses, or third-<span class=\"dictionary\">party<\/span> supplier as a condition of participation in a <span class=\"dictionary\">vision care plan<\/span>. <a id=\"paragraph-299222\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#D\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"E\"><p><span class=\"prefix-number\">E.<\/span> Any changes to a <span class=\"dictionary\">participating provider agreement<\/span> proposed by the <span class=\"dictionary\"><span class=\"dictionary\">vision care plan<\/span> carrier<\/span> shall be submitted in writing to the optometrist or ophthalmologist at least 30 days prior to the effective date of such proposed changes. <a id=\"paragraph-299223\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#E\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"F\"><p><span class=\"prefix-number\">F.<\/span> This section shall apply with respect to any <span class=\"dictionary\">participating provider agreement<\/span> that is entered into, amended, extended, or renewed on or after January 1, 2016. <a id=\"paragraph-299224\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#F\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"G\"><p><span class=\"prefix-number\">G.<\/span> The <span class=\"dictionary\">Commission<\/span> shall have no <span class=\"dictionary\">jurisdiction<\/span> to <span class=\"dictionary\">adjudicate<\/span> individual controversies arising out of this section. <a id=\"paragraph-299225\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#G\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"H\"><p><span class=\"prefix-number\">H.<\/span> The provisions of subsections B through G, as related to <span class=\"dictionary\">covered materials<\/span> only, shall be applicable to licensed opticians practicing in the Commonwealth. <a id=\"paragraph-299226\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.19\/#H\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>","plain_text":"                                 CODE OF VIRGINIA\n\nPAYMENT FOR SERVICES BY OPTOMETRISTS AND OPHTHALMOLOGISTS (\u00a7 38.2-3407.19)\n\nA. As used in this section, unless the context requires a different meaning:\n\t\t\t&#8220;Covered materials&#8221; means lenses, devices containing lenses,\nprisms, lens treatments and coatings, contact lenses, and devices to correct,\nrelieve, or treat defects or abnormal conditions of the human eye and its adnexa\nfor which benefits under a policy, contract, or evidence of coverage are payable\nby a vision care plan carrier, including materials paid by the insureds,\nsubscribers, or enrollees because the annual or periodic payment maximum\nestablished by the vision care plan has been met.\n\t\t\t&#8220;Covered services&#8221; means the health care services for which\nbenefits under a policy, contract, or evidence of coverage are payable by a\nvision care plan carrier, including services paid by the insureds, subscribers,\nor enrollees because the annual or periodic payment maximum established by the\nvision care plan has been met.\n\t\t\t&#8220;Enrollee&#8221; means any person entitled to health care services\nunder a vision care plan.\n\t\t\t&#8220;Optometric services plan&#8221; has the same meaning ascribed thereto\nin &#xA7; 38.2-4501.\n\t\t\t&#8220;Participating provider agreement&#8221; means a contract or agreement\nbetween an optometrist or ophthalmologist and a vision care plan carrier in\nwhich the optometrist or ophthalmologist has agreed to provide vision-related\nhealth care services to enrollees and to hold those enrollees harmless from\npayment with an expectation of receiving payment, other than copayments or\ndeductibles, directly or indirectly from a vision care plan.\n\t\t\t&#8220;Vision care plan&#8221; means (i) an individual or group accident and\nsickness insurance policy providing hospital, medical, and surgical or major\nmedical coverage on an expense-incurred basis; (ii) an individual or group\naccident and sickness subscription contract; (iii) an optometric services plan;\n(iv) a health care plan provided by a health maintenance organization; or (v) an\nintegrated or stand-alone vision benefit plan or a vision care insurance policy\nor contract that provides vision benefits to an enrollee pertaining to the\nprovision of covered services or covered materials, under which policy,\ncontract, or plan an enrollee is eligible to receive a benefit for covered\nservices or covered materials.\n\t\t\t&#8220;Vision care plan carrier&#8221; means (i) an insurer proposing to\nissue individual or group accident and sickness insurance policies providing\nhospital, medical, and surgical or major medical coverage on an expense-incurred\nbasis; (ii) a nonstock corporation providing individual or group accident and\nsickness subscription contracts; (iii) a nonstock corporation offering an\noptometric services plan; (iv) a health maintenance organization providing a\nhealth care plan; and (v) an entity that creates, promotes, sells, provides,\nadvertises, or administers (a) an integrated or stand-alone vision benefit plan\nor (b) a vision care insurance policy or contract that provides vision benefits\nto an enrollee pertaining to the provision of covered services or covered\nmaterials.\n\nB. No participating provider agreement shall establish the fee or rate that the\noptometrist or ophthalmologist is required to accept for the provision of health\ncare materials or services, or require that an optometrist or ophthalmologist\naccept the reimbursement paid as payment in full, unless the health care\nmaterials and services are covered materials or covered services under the\napplicable vision care plan.\n\nC. Reimbursement paid by the vision care plan carrier for covered services and\ncovered materials shall be reasonable and shall not provide nominal\nreimbursement in order to claim that services and materials are covered services\nor covered materials under the applicable vision care plan. For the purposes of\nthis subsection, &#8220;reasonable&#8221; means the negotiated fee or rate that\nis set forth in the participating provider agreement and is acceptable to the\nprovider.\n\nD. No vision care plan shall require an optometrist or ophthalmologist to use a\nparticular optical laboratory, manufacturer of eyeglass frames or contact\nlenses, or third-party supplier as a condition of participation in a vision care\nplan.\n\nE. Any changes to a participating provider agreement proposed by the vision care\nplan carrier shall be submitted in writing to the optometrist or ophthalmologist\nat least 30 days prior to the effective date of such proposed changes.\n\nF. This section shall apply with respect to any participating provider agreement\nthat is entered into, amended, extended, or renewed on or after January 1, 2016.\n\nG. The Commission shall have no jurisdiction to adjudicate individual\ncontroversies arising out of this section.\n\nH. The provisions of subsections B through G, as related to covered materials\nonly, shall be applicable to licensed opticians practicing in the Commonwealth.\n\nHISTORY: 2015, c. 723.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}