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LRB-2107/1
TJD:kjf
2017 - 2018 LEGISLATURE
June 2, 2017 - Introduced by Representatives Riemer, Kolste, C. Taylor,
Anderson, Barca, Berceau, Billings, Bowen, Brostoff, Considine, Crowley,
Doyle, Fields, Genrich, Goyke, Hebl, Hesselbein, Hintz, Kessler, Mason,
Meyers, Ohnstad, Pope, Sargent, Shankland, Sinicki, Spreitzer, Stuck,
Subeck, Vruwink, Wachs, Young, Zamarripa and Zepnick, cosponsored by
Senators Erpenbach, Johnson, Shilling, Bewley, Carpenter, Hansen,
Larson, Miller, Ringhand, Risser, L. Taylor, Vinehout and Wirch. Referred
to Committee on Insurance.
AB362,1,3 1An Act to create 609.713 and 632.895 (14m) of the statutes; relating to:
2coverage of certain essential health benefits by health insurance policies and
3plans and requiring the exercise of rule-making authority.
Analysis by the Legislative Reference Bureau
This bill requires health insurance policies, known in the bill as disability
insurance policies, and governmental self-insured health plans to cover essential
health benefits that will be specified by the commissioner of the Office of the
Commissioner of Insurance by rule. The bill specifies a list of requirements that the
commissioner must follow when establishing the essential health benefits including
certain limitations on cost sharing and the following general categories of benefits,
items, or services in which the commissioner must require coverage: ambulatory
patient services, emergency services, hospitalization, maternity and newborn care,
mental health and substance use disorder services, prescription drugs,
rehabilitative and habilitative services and devices, laboratory services, preventive
and wellness services and chronic disease management, and pediatric services. If
an essential health benefit specified by the commissioner is also subject to its own
mandated coverage requirement, the bill requires the disability insurance policy or
self-insured health plan to provide coverage under whichever requirement provides
the insured or plan participant with more comprehensive coverage.

This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB362,1 1Section 1. 609.713 of the statutes is created to read:
AB362,2,3 2609.713 Essential health benefits. Defined network plans and preferred
3provider plans are subject to s. 632.895 (14m).
AB362,2 4Section 2. 632.895 (14m) of the statutes is created to read:
AB362,2,65 632.895 (14m) Essential health benefits. (a) In this section, “self-insured
6health plan” has the meaning given in s. 632.85 (1) (c).
AB362,2,97 (b) On a date specified by the commissioner, by rule, every disability insurance
8policy and every self-insured health plan shall provide coverage for essential health
9benefits as determined by the commissioner, by rule, subject to par. (c).
AB362,2,1110 (c) In determining the essential health benefits for which coverage is required
11under par. (b), the commissioner shall do all of the following:
AB362,2,1312 1. Include benefits, items, and services in, at least, all of the following
13categories:
AB362,2,1414 a. Ambulatory patient services.
AB362,2,1515 b. Emergency services.
AB362,2,1616 c. Hospitalization.
AB362,2,1717 d. Maternity and newborn care.
AB362,2,1918 e. Mental health and substance use disorder services, including behavioral
19health treatment.
AB362,2,2020 f. Prescription drugs.
AB362,2,2121 g. Rehabilitative and habilitative services and devices.
AB362,3,1
1h. Laboratory services.
AB362,3,22 i. Preventive and wellness services and chronic disease management.
AB362,3,33 j. Pediatric services, including oral and vision care.
AB362,3,84 2. Conduct a survey of employer-sponsored coverage to determine benefits
5typically covered by employers and ensure that the scope of essential health benefits
6for which coverage is required under this subsection is equal to the scope of benefits
7covered under a typical disability insurance policy offered by an employer to its
8employees.
AB362,3,109 3. Ensure that essential health benefits reflect a balance among the categories
10described in subd. 1. such that benefits are not unduly weighted toward one category.
AB362,3,1211 4. Ensure that essential health benefit coverage is provided with no or limited
12cost-sharing requirements.
AB362,3,1613 5. Require that disability insurance policies and self-insured health plans do
14not make coverage decisions, determine reimbursement rates, establish incentive
15programs, or design benefits in ways that discriminate against individuals because
16of their age, disability, or expected length of life.
AB362,3,1917 6. Establish essential health benefits in a way that takes account of the health
18care needs of diverse segments of the population, including women, children, persons
19with disabilities, and other groups.
AB362,3,2320 7. Ensure that essential health benefits established under this subsection not
21be subject to a coverage denial based on an insured's or plan participant's age,
22expected length of life, present or predicted disability, degree of dependency on
23medical care, or quality of life.
AB362,4,524 8. Require that disability insurance policies and self-insured health plans
25cover emergency department services that are essential health benefits without

1imposing any requirement to obtain prior authorization for those services and
2without limiting coverage for services provided by an emergency services provider
3that is not in the provider network of a policy or plan in a way that is more restrictive
4than requirements or limitations that apply to emergency services provided by a
5provider that is in the provider network of the policy or plan.
AB362,4,106 9. Require a disability insurance policy or self-insured health plan to apply to
7emergency department services that are essential health benefits provided by an
8emergency department provider that is not in the provider network of the policy or
9plan the same copayment amount or coinsurance rate that applies if those services
10are provided by a provider that is in the provider network of the policy or plan.
AB362,4,1211 (d) The commissioner shall periodically update, by rule, the essential health
12benefits under this subsection to address any gaps in access to coverage.
AB362,4,1713 (e) If an essential health benefit is also subject to mandated coverage elsewhere
14under this section and the coverage requirements are not identical, the disability
15insurance policy or self-insured health plan shall provide coverage under whichever
16subsection provides the insured or plan participant with more comprehensive
17coverage of the medical condition, item, or service.
AB362,4,2118 (f) Nothing in this subsection or rules promulgated under this subsection
19prohibits a disability insurance policy or a self-insured health plan from providing
20benefits in excess of the essential health benefit coverage required under this
21subsection.
AB362,4,2222 (End)
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