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SB37,18,1111 n. Influenza.
SB37,18,1212 o. Rotavirus.
SB37,31 13Section 31. 632.895 (14) (b) of the statutes is amended to read:
SB37,18,1914 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy,
15and every self-insured health plan of the state or a county, city, town, village, or
16school district, that provides coverage for a dependent of the insured shall provide
17coverage of appropriate and necessary immunizations, from birth to the age of 6
18years,
for an insured or plan participant, including a dependent who is a child of the
19insured or plan participant.
SB37,32 20Section 32. 632.895 (14) (c) of the statutes is amended to read:
SB37,18,2521 632.895 (14) (c) The coverage required under par. (b) may not be subject to any
22deductibles, copayments, or coinsurance under the policy or plan. This paragraph
23applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to
24appropriate and necessary immunizations provided by providers participating, as
25defined in s. 609.01 (3m), in the plan.
SB37,33
1Section 33. 632.895 (14) (d) 3. of the statutes is amended to read:
SB37,19,42 632.895 (14) (d) 3. A health care plan offered by a limited service health
3organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined
4in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b)
.
SB37,34 5Section 34. 632.895 (14m) of the statutes is created to read:
SB37,19,76 632.895 (14m) Essential health benefits. (a) In this subsection,
7“self-insured health plan” has the meaning given in s. 632.85 (1) (c).
SB37,19,118 (b) On a date specified by the commissioner, by rule, every disability insurance
9policy, except as provided in par. (g), and every self-insured health plan shall provide
10coverage for essential health benefits as determined by the commissioner, by rule,
11subject to par. (c).
SB37,19,1312 (c) In determining the essential health benefits for which coverage is required
13under par. (b), the commissioner shall do all of the following:
SB37,19,1514 1. Include benefits, items, and services in, at least, all of the following
15categories:
SB37,19,1616 a. Ambulatory patient services.
SB37,19,1717 b. Emergency services.
SB37,19,1818 c. Hospitalization.
SB37,19,1919 d. Maternity and newborn care.
SB37,19,2120 e. Mental health and substance use disorder services, including behavioral
21health treatment.
SB37,19,2222 f. Prescription drugs.
SB37,19,2323 g. Rehabilitative and habilitative services and devices.
SB37,19,2424 h. Laboratory services.
SB37,19,2525 i. Preventive and wellness services and chronic disease management.
SB37,20,1
1j. Pediatric services, including oral and vision care.
SB37,20,62 2. Conduct a survey of employer-sponsored coverage to determine benefits
3typically covered by employers and ensure that the scope of essential health benefits
4for which coverage is required under this subsection is equal to the scope of benefits
5covered under a typical disability insurance policy offered by an employer to its
6employees.
SB37,20,87 3. Ensure that essential health benefits reflect a balance among the categories
8described in subd. 1. such that benefits are not unduly weighted toward one category.
SB37,20,109 4. Ensure that essential health benefit coverage is provided with no or limited
10cost-sharing requirements.
SB37,20,1411 5. Require that disability insurance policies and self-insured health plans do
12not make coverage decisions, determine reimbursement rates, establish incentive
13programs, or design benefits in ways that discriminate against individuals because
14of their age, disability, or expected length of life.
SB37,20,1715 6. Establish essential health benefits in a way that takes into account the
16health care needs of diverse segments of the population, including women, children,
17persons with disabilities, and other groups.
SB37,20,2118 7. Ensure that essential health benefits established under this subsection are
19not subject to a coverage denial based on an insured's or plan participant's age,
20expected length of life, present or predicted disability, degree of dependency on
21medical care, or quality of life.
SB37,21,322 8. Require that disability insurance policies and self-insured health plans
23cover emergency department services that are essential health benefits without
24imposing any requirement to obtain prior authorization for those services and
25without limiting coverage for services provided by an emergency services provider

1that is not in the provider network of a policy or plan in a way that is more restrictive
2than requirements or limitations that apply to emergency services provided by a
3provider that is in the provider network of the policy or plan.
SB37,21,84 9. Require a disability insurance policy or self-insured health plan to apply to
5emergency department services that are essential health benefits provided by an
6emergency department provider that is not in the provider network of the policy or
7plan the same copayment amount or coinsurance rate that applies if those services
8are provided by a provider that is in the provider network of the policy or plan.
SB37,21,109 (d) The commissioner shall periodically update, by rule, the essential health
10benefits under this subsection to address any gaps in access to coverage.
SB37,21,1511 (e) If an essential health benefit is also subject to mandated coverage elsewhere
12under this section and the coverage requirements are not identical, the disability
13insurance policy or self-insured health plan shall provide coverage under whichever
14subsection provides the insured or plan participant with more comprehensive
15coverage of the medical condition, item, or service.
SB37,21,1916 (f) Nothing in this subsection or rules promulgated under this subsection
17prohibits a disability insurance policy or a self-insured health plan from providing
18benefits in excess of the essential health benefit coverage required under this
19subsection.
SB37,21,2120 (g) This subsection does not apply to any disability insurance policy that is
21described in s. 632.745 (11) (b) 1. to 12.
SB37,35 22Section 35. 632.895 (16m) (b) of the statutes is amended to read:
SB37,22,223 632.895 (16m) (b) The coverage required under this subsection may be subject
24to any limitations, or exclusions, or cost-sharing provisions that apply generally
25under the disability insurance policy or self-insured health plan. The coverage

1required under this subsection may not be subject to any deductibles, copayments,
2or coinsurance.
SB37,36 3Section 36. 632.895 (17) (b) 2. of the statutes is amended to read:
SB37,22,84 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and
5medical services that are necessary to prescribe, administer, maintain, or remove a
6contraceptive, if covered for any other drug benefits under the policy or plan
7sterilization procedures, and patient education and counseling for all females with
8reproductive capacity
.
SB37,37 9Section 37. 632.895 (17) (c) of the statutes is amended to read:
SB37,22,2410 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions,
11and limitations, or cost-sharing provisions that apply generally to the coverage of
12outpatient health care services, preventive treatments and services, or prescription
13drugs and devices that is provided under the policy or self-insured health plan. A
14disability insurance policy or self-insured health plan may not apply a deductible or
15impose a copayment or coinsurance to at least one of each type of contraceptive
16method approved by the federal food and drug administration for which coverage is
17required under this subsection. The disability insurance policy or self-insured
18health plan may apply reasonable medical management to a method of contraception
19to limit coverage under this subsection that is provided without being subject to a
20deductible, copayment, or coinsurance to prescription drugs without a brand name.
21The disability insurance policy or self-insured health plan may apply a deductible
22or impose a copayment or coinsurance for coverage of a contraceptive that is
23prescribed for a medical need if the services for the medical need would otherwise be
24subject to a deductible, copayment, or coinsurance.
SB37,38 25Section 38. 632.897 (11) (a) of the statutes is amended to read:
SB37,23,9
1632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may
2promulgate rules establishing standards requiring insurers to provide continuation
3of coverage for any individual covered at any time under a group policy who is a
4terminated insured or an eligible individual under any federal program that
5provides for a federal premium subsidy for individuals covered under continuation
6of coverage under a group policy, including rules governing election or extension of
7election periods, notice, rates, premiums, premium payment, application of
8preexisting condition exclusions,
election of alternative coverage, and status as an
9eligible individual, as defined in s. 149.10 (2t), 2011 stats.
SB37,39 10Section 39. Initial applicability.
SB37,23,1311 (1) For policies and plans containing provisions inconsistent with this act, this
12act first applies to policy or plan years beginning on January 1 of the year following
13the year in which this subsection takes effect, except as provided in sub. (2).
SB37,23,1814 (2) For policies or plans that are affected by a collective bargaining agreement
15containing provisions inconsistent with this act, this act first applies to policy or plan
16years beginning on the effective date of this subsection or on the day on which the
17collective bargaining agreement is entered into, extended, modified, or renewed,
18whichever is later.
SB37,40 19Section 40 . Effective date.
SB37,23,2120 (1) This act takes effect on the first day of the 4th month beginning after
21publication.
SB37,23,2222 (End)
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