Amendment AA2-ASA2-AB68

AB68-ASA2-AA2,72,5 3. The notice includes a list of the participating providers at the facility that would be able to provide the item or service and notification that the enrollee may be referred to one of those participating providers.

AB68-ASA2-AA2,72,8 4. The notice includes information about whether or not prior authorization or other care management limitations may be required before receiving an item or service at the participating facility.

AB68-ASA2-AA2,72,13 5. The enrollee provides consent to the provider to be treated by the nonparticipating provider, and the consent acknowledges that the enrollee has been informed that the charge paid by the enrollee may not meet a limitation that the enrollee's defined network plan, preferred provider plan, or self-insured governmental plan places on cost sharing, such as an in-network deductible.

AB68-ASA2-AA2,72,15 6. A signed copy of the consent described under subd. 5. is provided to the enrollee.

AB68-ASA2-AA2,72,17 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

AB68-ASA2-AA2,72,21 1. If the enrollee makes an appointment for the item or service at least 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee at least 72 hours before the day of the appointment at which the item or service is to be provided.

AB68-ASA2-AA2,72,24 2. If the enrollee makes an appointment for the item or service less than 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee on the day that the appointment is made.

AB68-ASA2-AA2,73,6 (c) A provider of an item or service that is entitled to payment under sub. (4) may not bill or hold liable an enrollee for any amount for the ancillary item or service that is more than the cost-sharing amount determined under sub. (4) (b) for the item or service, unless the commissioner specifies by rule that the provider may balance bill for the specified item or service, if the ancillary item or service is any of the following:

AB68-ASA2-AA2,73,7 1. Related to an emergency medical service.

AB68-ASA2-AA2,73,8 2. Anesthesiology.

AB68-ASA2-AA2,73,9 3. Pathology.

AB68-ASA2-AA2,73,10 4. Radiology.

AB68-ASA2-AA2,73,11 5. Neonatology.

AB68-ASA2-AA2,73,12 6. A item or service provided by an assistant surgeon, hospitalist, or intensivist.

AB68-ASA2-AA2,73,13 7. Diagnostic service, including a radiology or laboratory service.

AB68-ASA2-AA2,73,15 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

AB68-ASA2-AA2,73,18 9. An item or service provided by a nonparticipating provider when there is no participating provider who can furnish the item or service at the participating facility.

AB68-ASA2-AA2,74,3 (6) Notice by provider or facility. Beginning no later than January 1, 2022, a health care provider or health care facility shall make available, including posting on an Internet site, to enrollees in defined network plans, preferred provider plans, and self-insured governmental plans notice of the requirements on a provider or facility under subs. (3) and (5), of any other applicable state law requirements on the provider or facility with respect to charging an enrollee for an item or service if the provider or facility does not have a contractual relationship with the plan, and of information on contacting appropriate state or federal agencies in the event the enrollee believes the provider or facility violates any of the requirements under this section or other applicable law.

AB68-ASA2-AA2,74,20 (7) Negotiation; dispute resolution. A provider or facility that is entitled to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (4) (c) may initiate, within 30 days of receiving the initial payment or notice of denial, open negotiations with the defined network plan, preferred provider plan, or self-insured governmental plan to determine a payment amount for the emergency medical service or other item or service for a period that terminates 30 days after initiating open negotiations. If the open negotiation period under this subsection terminates without determination of a payment amount, the provider, facility, defined network plan, preferred provider plan, or self-insured governmental plan may initiate, within the 4 days beginning on the day after the open negotiation period ends, the independent dispute resolution process as specified by the commissioner. If the independent dispute resolution decision maker determines the payment amount, the party to the independent dispute resolution process whose amount was not selected shall pay the fees for the independent dispute resolution. If the parties to the independent dispute resolution reach a settlement on the payment amount, the parties to the independent dispute resolution shall equally divide the payment for the fees for the independent dispute resolution.

AB68-ASA2-AA2,74,21 (8) Continuity of care. (a) In this subsection:

AB68-ASA2-AA2,74,22 1. “Continuing care patient” means an individual who is any of the following:

AB68-ASA2-AA2,74,24 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB68-ASA2-AA2,75,2 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB68-ASA2-AA2,75,4 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB68-ASA2-AA2,75,6 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB68-ASA2-AA2,75,8 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB68-ASA2-AA2,75,9 2. “Serious and complex condition” means any of the following:

AB68-ASA2-AA2,75,12 a. In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.

AB68-ASA2-AA2,75,15 b. In the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized medical care over a prolonged period of time.

AB68-ASA2-AA2,75,21 (b) If an enrollee is a continuing care patient and is obtaining items or services from a participating provider or facility and the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the participating provider or facility is terminated or the coverage of benefits that include the items or services provided by the participating provider or facility are terminated by the plan, the plan shall do all of the following:

AB68-ASA2-AA2,75,24 1. Notify each enrollee of the termination of the contract or benefits and of the right for the enrollee to elect to continue transitional care from the provider or facility under this subsection.

AB68-ASA2-AA2,76,2 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB68-ASA2-AA2,76,9 3. Allow the enrollee to elect to continue to have the benefits provided under the plan under the same terms and conditions as would have applied to the item or service if the termination had not occurred for the course of treatment related to the enrollee's status as a continuing care patient beginning on the date on which the notice under subd. 1. is provided and ending 90 days after the date on which the notice under subd. 1. is provided or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.

AB68-ASA2-AA2,76,13 (9) Rule making. The commissioner may promulgate any rules necessary to implement this section, including specifying the independent dispute resolution process. The commissioner may promulgate rules to modify the list of those items and services for which a provider may not balance bill under sub. (5) (c).

AB68-ASA2-AA2,412c Section 412c. 609.713 of the statutes is created to read:

AB68-ASA2-AA2,76,16 609.713 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB68-ASA2-AA2,412d Section 412d. 609.719 of the statutes is created to read:

AB68-ASA2-AA2,76,19 609.719 Telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB68-ASA2-AA2,412e Section 412e. 609.83 of the statutes, as affected by 2021 Wisconsin Act 9, is amended to read:

AB68-ASA2-AA2,76,24 609.83 Coverage of drugs and devices ; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).

AB68-ASA2-AA2,412f Section 412f. 609.83 of the statutes, as affected by 2021 Wisconsin Act .... (this act), section 412e, is amended to read:

AB68-ASA2-AA2,77,6 609.83 Coverage of drugs and devices; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and (16v).

AB68-ASA2-AA2,412g Section 412g. 609.847 of the statutes is created to read:

AB68-ASA2-AA2,77,10 609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

AB68-ASA2-AA2,412h Section 412h. 625.12 (1) (a) of the statutes is amended to read:

AB68-ASA2-AA2,77,13 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB68-ASA2-AA2,412i Section 412i. 625.12 (1) (e) of the statutes is amended to read:

AB68-ASA2-AA2,77,16 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB68-ASA2-AA2,412j Section 412j. 625.12 (2) of the statutes is amended to read:

AB68-ASA2-AA2,78,2 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB68-ASA2-AA2,412k Section 412k. 625.15 (1) of the statutes is amended to read:

AB68-ASA2-AA2,78,11 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB68-ASA2-AA2,412L Section 412L. 628.34 (3) (a) of the statutes is amended to read:

AB68-ASA2-AA2,78,20 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB68-ASA2-AA2,412m Section 412m. 628.34 (3) (a) of the statutes, as affected by 2021 Wisconsin Act .... (this act), section 412L, is amended to read:

AB68-ASA2-AA2,79,5 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB68-ASA2-AA2,412n Section 412n. 632.728 of the statutes is created to read:

AB68-ASA2-AA2,79,8 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB68-ASA2-AA2,79,10 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB68-ASA2-AA2,79,11 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB68-ASA2-AA2,79,12 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68-ASA2-AA2,79,18 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB68-ASA2-AA2,79,21 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB68-ASA2-AA2,80,2 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68-ASA2-AA2,80,3 1. Health status.

AB68-ASA2-AA2,80,4 2. Medical condition, including both physical and mental illnesses.

AB68-ASA2-AA2,80,5 3. Claims experience.

AB68-ASA2-AA2,80,6 4. Receipt of health care.

AB68-ASA2-AA2,80,7 5. Medical history.

AB68-ASA2-AA2,80,8 6. Genetic information.

AB68-ASA2-AA2,80,10 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-ASA2-AA2,80,11 8. Disability.

AB68-ASA2-AA2,80,18 (b) An insurer offering an individual health benefit plan or a self-insured health plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-ASA2-AA2,80,22 (c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

AB68-ASA2-AA2,80,25 (4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

AB68-ASA2-AA2,81,1 (a) Whether the policy or plan covers an individual or a family.

AB68-ASA2-AA2,81,2 (b) Rating area in the state, as established by the commissioner.

AB68-ASA2-AA2,81,5 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

AB68-ASA2-AA2,81,6 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-ASA2-AA2,81,11 (5) Statewide risk pool. An insurer offering a health benefit plan may not segregate enrollees into risk pools other than a single statewide risk pool for the individual market and a single statewide risk pool for the small employer market or a single statewide risk pool that combines the individual and small employer markets.

AB68-ASA2-AA2,81,13 (6) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

AB68-ASA2-AA2,81,15 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,17 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-ASA2-AA2,81,21 (7) Cost sharing maximum. A health benefit plan offered on the individual or small employer market may not require an enrollee under the plan to pay more in cost sharing than the maximum amount calculated under 42 USC 18022 (c), including the annual indexing of the limits.

AB68-ASA2-AA2,81,24 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

AB68-ASA2-AA2,82,2 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB68-ASA2-AA2,82,4 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB68-ASA2-AA2,82,8 (9) Actuarial values of plan tiers. Any health benefit plan offered on the individual or small employer market shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan.

AB68-ASA2-AA2,412p Section 412p. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read: