AB1185: Bill Text

AB1185,7,7 2. The notice provides a good faith estimate of the amount that the provider may charge the enrollee for the item or service involved, including notification that the estimate does not constitute a contract with respect to the charges estimated for the item or service.

AB1185,7,10 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.

AB1185,7,13 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.

AB1185,7,18 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.

AB1185,7,20 6. A signed copy of the consent described under subd. 5. is provided to the enrollee.

AB1185,7,22 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

AB1185,8,2 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.

AB1185,8,5 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.

AB1185,8,11 (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:

AB1185,8,12 1. Related to an emergency medical service.

AB1185,8,13 2. Anesthesiology.

AB1185,8,14 3. Pathology.

AB1185,8,15 4. Radiology.

AB1185,8,16 5. Neonatology.

AB1185,8,17 6. A item or service provided by an assistant surgeon, hospitalist, or intensivist.

AB1185,8,18 7. Diagnostic service, including a radiology or laboratory service.

AB1185,8,20 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

AB1185,8,23 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.

AB1185,9,8 (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.

AB1185,9,25 (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.

AB1185,10,1 (8) Continuity of care. (a) In this subsection:

AB1185,10,2 1. “Continuing care patient” means an individual who is any of the following:

AB1185,10,4 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB1185,10,6 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB1185,10,8 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB1185,10,10 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB1185,10,12 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB1185,10,13 2. “Serious and complex condition” means any of the following:

AB1185,10,16 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.

AB1185,10,19 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.

AB1185,10,25 (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:

AB1185,11,3 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.

AB1185,11,5 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB1185,11,12 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.

AB1185,11,16 (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).

AB1185,11,17 (End)