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AB1185,7,1311 4. The notice includes information about whether or not prior authorization or
12other care management limitations may be required before receiving an item or
13service at the participating facility.
AB1185,7,1814 5. The enrollee provides consent to the provider to be treated by the
15nonparticipating provider, and the consent acknowledges that the enrollee has been
16informed that the charge paid by the enrollee may not meet a limitation that the
17enrollee's defined network plan, preferred provider plan, or self-insured
18governmental plan places on cost sharing, such as an in-network deductible.
AB1185,7,2019 6. A signed copy of the consent described under subd. 5. is provided to the
20enrollee.
AB1185,7,2221 (b) To be considered adequate, the notice and consent under par. (a) shall meet
22one of the following requirements, as applicable:
AB1185,8,223 1. If the enrollee makes an appointment for the item or service at least 72 hours
24before the day on which the item or service is to be provided, any notice under par.

1(a) shall be provided to the enrollee at least 72 hours before the day of the
2appointment at which the item or service is to be provided.
AB1185,8,53 2. If the enrollee makes an appointment for the item or service less than 72
4hours before the day on which the item or service is to be provided, any notice under
5par. (a) shall be provided to the enrollee on the day that the appointment is made.
AB1185,8,116 (c) A provider of an item or service that is entitled to payment under sub. (4)
7may not bill or hold liable an enrollee for any amount for the ancillary item or service
8that is more than the cost-sharing amount determined under sub. (4) (b) for the item
9or service, unless the commissioner specifies by rule that the provider may balance
10bill for the specified item or service, if the ancillary item or service is any of the
11following:
AB1185,8,1212 1. Related to an emergency medical service.
AB1185,8,1313 2. Anesthesiology.
AB1185,8,1414 3. Pathology.
AB1185,8,1515 4. Radiology.
AB1185,8,1616 5. Neonatology.
AB1185,8,1717 6. A item or service provided by an assistant surgeon, hospitalist, or intensivist.
AB1185,8,1818 7. Diagnostic service, including a radiology or laboratory service.
AB1185,8,2019 8. An item or service provided by a specialty practitioner that the commissioner
20specifies by rule.
AB1185,8,2321 9. An item or service provided by a nonparticipating provider when there is no
22participating provider who can furnish the item or service at the participating
23facility.
AB1185,9,8 24(6) Notice by provider or facility. Beginning no later than January 1, 2022,
25a health care provider or health care facility shall make available, including posting

1on an Internet site, to enrollees in defined network plans, preferred provider plans,
2and self-insured governmental plans notice of the requirements on a provider or
3facility under subs. (3) and (5), of any other applicable state law requirements on the
4provider or facility with respect to charging an enrollee for an item or service if the
5provider or facility does not have a contractual relationship with the plan, and of
6information on contacting appropriate state or federal agencies in the event the
7enrollee believes the provider or facility violates any of the requirements under this
8section or other applicable law.
AB1185,9,25 9(7) Negotiation; dispute resolution. A provider or facility that is entitled to
10receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (4) (c) may
11initiate, within 30 days of receiving the initial payment or notice of denial, open
12negotiations with the defined network plan, preferred provider plan, or self-insured
13governmental plan to determine a payment amount for the emergency medical
14service or other item or service for a period that terminates 30 days after initiating
15open negotiations. If the open negotiation period under this subsection terminates
16without determination of a payment amount, the provider, facility, defined network
17plan, preferred provider plan, or self-insured governmental plan may initiate,
18within the 4 days beginning on the day after the open negotiation period ends, the
19independent dispute resolution process as specified by the commissioner. If the
20independent dispute resolution decision maker determines the payment amount,
21the party to the independent dispute resolution process whose amount was not
22selected shall pay the fees for the independent dispute resolution. If the parties to
23the independent dispute resolution reach a settlement on the payment amount, the
24parties to the independent dispute resolution shall equally divide the payment for
25the fees for the independent dispute resolution.
AB1185,10,1
1(8) Continuity of care. (a) In this subsection:
AB1185,10,22 1. “Continuing care patient” means an individual who is any of the following:
AB1185,10,43 a. Undergoing a course of treatment for a serious and complex condition from
4a provider or facility.
AB1185,10,65 b. Undergoing a course of institutional or inpatient care from a provider or
6facility.
AB1185,10,87 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
8care, from a provider or facility.
AB1185,10,109 d. Pregnant and undergoing a course of treatment for the pregnancy from a
10provider or facility.
AB1185,10,1211 e. Terminally ill and receiving treatment for the illness from a provider or
12facility.
AB1185,10,1313 2. “Serious and complex condition” means any of the following:
AB1185,10,1614 a. In the case of an acute illness, a condition that is serious enough to require
15specialized medical treatment to avoid the reasonable possibility of death or
16permanent harm.
AB1185,10,1917 b. In the case of a chronic illness or condition, a condition that is
18life-threatening, degenerative, potentially disabling, or congenital and requires
19specialized medical care over a prolonged period of time.
AB1185,10,2520 (b) If an enrollee is a continuing care patient and is obtaining items or services
21from a participating provider or facility and the contract between the defined
22network plan, preferred provider plan, or self-insured governmental plan and the
23participating provider or facility is terminated or the coverage of benefits that
24include the items or services provided by the participating provider or facility are
25terminated by the plan, the plan shall do all of the following:
AB1185,11,3
11. Notify each enrollee of the termination of the contract or benefits and of the
2right for the enrollee to elect to continue transitional care from the provider or facility
3under this subsection.
AB1185,11,54 2. Provide the enrollee an opportunity to notify the plan of the need for
5transitional care.
AB1185,11,126 3. Allow the enrollee to elect to continue to have the benefits provided under
7the plan under the same terms and conditions as would have applied to the item or
8service if the termination had not occurred for the course of treatment related to the
9enrollee's status as a continuing care patient beginning on the date on which the
10notice under subd. 1. is provided and ending 90 days after the date on which the
11notice under subd. 1. is provided or the date on which the enrollee is no longer a
12continuing care patient, whichever is earlier.
AB1185,11,16 13(9) Rule making. The commissioner may promulgate any rules necessary to
14implement this section, including specifying the independent dispute resolution
15process. The commissioner may promulgate rules to modify the list of those items
16and services for which a provider may not balance bill under sub. (5) (c).
AB1185,11,1717 (End)
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