Amendment AA2-ASA1-AB1

AB1-ASA1-AA2,2,11 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB1-ASA1-AA2,2,13 (2) An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

AB1-ASA1-AA2,2,15 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB1-ASA1-AA2,2,17 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB1-ASA1-AA2,2,23 (3) For the purpose of setting rates or premiums for coverage under a group or individual heath benefit plan or a self-insured health plan and for the purpose of setting any deductibles, copayments, or coinsurance under a group or individual health benefit plan or a self-insured health plan, the plan may not consider whether an individual, including a dependent, who would be covered under the plan has a preexisting condition.

AB1-ASA1-AA2,7s Section 7s. 632.895 (14m) of the statutes is created to read:

AB1-ASA1-AA2,3,2 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB1-ASA1-AA2,3,6 (b) On a date specified by the commissioner, by rule, every disability insurance policy, except as provided in par. (g), and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB1-ASA1-AA2,3,8 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB1-ASA1-AA2,3,10 1. Include benefits, items, and services in, at least, all of the following categories:

AB1-ASA1-AA2,3,11 a. Ambulatory patient services.

AB1-ASA1-AA2,3,12 b. Emergency services.

AB1-ASA1-AA2,3,13 c. Hospitalization.

AB1-ASA1-AA2,3,14 d. Maternity and newborn care.

AB1-ASA1-AA2,3,16 e. Mental health and substance use disorder services, including behavioral health treatment.

AB1-ASA1-AA2,3,17 f. Prescription drugs.

AB1-ASA1-AA2,3,18 g. Rehabilitative and habilitative services and devices.

AB1-ASA1-AA2,3,19 h. Laboratory services.

AB1-ASA1-AA2,3,20 i. Preventive and wellness services and chronic disease management.

AB1-ASA1-AA2,3,21 j. Pediatric services, including oral and vision care.

AB1-ASA1-AA2,4,2 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB1-ASA1-AA2,4,4 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB1-ASA1-AA2,4,6 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB1-ASA1-AA2,4,10 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB1-ASA1-AA2,4,13 6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB1-ASA1-AA2,4,17 7. Ensure that essential health benefits established under this subsection are not subject to a coverage denial based on an insured's or plan participant's age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB1-ASA1-AA2,4,24 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB1-ASA1-AA2,5,5 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB1-ASA1-AA2,5,7 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB1-ASA1-AA2,5,12 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB1-ASA1-AA2,5,16 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.

AB1-ASA1-AA2,5,18 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

AB1-ASA1-AA2,8m Section 8m. Initial applicability.

AB1-ASA1-AA2,5,23 (1) Lifetime and annual limits. For policies and plans containing provisions inconsistent with s. 632.883, the treatment of s. 632.883 first applies to plan years beginning on January 1 of the year following the year in which this subsection takes effect.”.

AB1-ASA1-AA2,5,24 (End)

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.