Amendment AA3-SB70

SB70-AA3,47,3 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for an insured or plan participant, including a dependent who is a child of the insured or plan participant.

SB70-AA3,29 Section 29. 632.895 (14) (c) of the statutes is amended to read:

SB70-AA3,47,9 632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

SB70-AA3,30 Section 30. 632.895 (14) (d) 3. of the statutes is amended to read:

SB70-AA3,47,13 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

SB70-AA3,31 Section 31. 632.895 (14m) of the statutes is created to read:

SB70-AA3,47,16 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB70-AA3,47,20 (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).

SB70-AA3,47,22 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

SB70-AA3,47,24 1. Include benefits, items, and services in, at least, all of the following categories:

SB70-AA3,47,25 a. Ambulatory patient services.

SB70-AA3,48,1 b. Emergency services.

SB70-AA3,48,2 c. Hospitalization.

SB70-AA3,48,3 d. Maternity and newborn care.

SB70-AA3,48,5 e. Mental health and substance use disorder services, including behavioral health treatment.

SB70-AA3,48,6 f. Prescription drugs.

SB70-AA3,48,7 g. Rehabilitative and habilitative services and devices.

SB70-AA3,48,8 h. Laboratory services.

SB70-AA3,48,9 i. Preventive and wellness services and chronic disease management.

SB70-AA3,48,10 j. Pediatric services, including oral and vision care.

SB70-AA3,48,15 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.

SB70-AA3,48,17 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.

SB70-AA3,48,19 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

SB70-AA3,48,23 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.

SB70-AA3,49,3 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.

SB70-AA3,49,7 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.

SB70-AA3,49,14 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.

SB70-AA3,49,19 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.

SB70-AA3,49,21 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

SB70-AA3,50,2 (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.

SB70-AA3,50,6 (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.

SB70-AA3,50,8 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

SB70-AA3,32 Section 32. 632.895 (16m) (b) of the statutes is amended to read:

SB70-AA3,50,14 632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions , or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.

SB70-AA3,33 Section 33. 632.895 (17) (b) 2. of the statutes is amended to read:

SB70-AA3,50,20 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.

SB70-AA3,34 Section 34. 632.895 (17) (c) of the statutes is amended to read:

SB70-AA3,51,11 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions, and limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan. A disability insurance policy or self-insured health plan may not apply a deductible or impose a copayment or coinsurance to at least one of each type of contraceptive method approved by the federal food and drug administration for which coverage is required under this subsection. The disability insurance policy or self-insured health plan may apply reasonable medical management to a method of contraception to limit coverage under this subsection that is provided without being subject to a deductible, copayment, or coinsurance to prescription drugs without a brand name. The disability insurance policy or self-insured health plan may apply a deductible or impose a copayment or coinsurance for coverage of a contraceptive that is prescribed for a medical need if the services for the medical need would otherwise be subject to a deductible, copayment, or coinsurance.

SB70-AA3,35 Section 35. 632.897 (11) (a) of the statutes is amended to read:

SB70-AA3,51,21 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t), 2011 stats.

SB70-AA3,9323 Section 9323. Initial applicability; Insurance.

SB70-AA3,51,24 (1u) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services.

SB70-AA3,52,7 (a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB70-AA3,52,15 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is entered into, extended, modified, or renewed, whichever is later.

SB70-AA3,9423 Section 9423. Effective dates; Insurance.

SB70-AA3,52,23 (1v) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services. The treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) and Section 9323 (1u) of this act take effect on the first day of the 4th month beginning after publication.”.

SB70-AA3,52,24 180. Page 374, line 11: after that line insert:

SB70-AA3,53,1 “ Section 36. 609.20 (3) of the statutes is created to read:

SB70-AA3,53,8 609.20 (3) The commissioner may promulgate rules to establish minimum network time and distance standards and minimum network wait-time standards for defined network plans and preferred provider plans. In promulgating rules under this subsection, the commissioner shall consider standards adopted by the federal centers for medicare and medicaid services for qualified health plans, as defined in 42 USC 18021 (a), that are offered through the federal health insurance exchange established pursuant to 42 USC 18041 (c).”.

SB70-AA3,53,9 181. Page 374, line 11: after that line insert:

SB70-AA3,53,10 “ Section 37. 609.045 of the statutes is created to read:

SB70-AA3,53,12 609.045 Balance billing; emergency medical services. (1) Definitions. In this section:

SB70-AA3,53,13 (a) “Emergency medical condition” means all of the following:

SB70-AA3,53,17 1. A medical condition, including a mental health condition or substance use disorder condition, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

SB70-AA3,53,19 a. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

SB70-AA3,53,20 b. Serious impairment of bodily function.

SB70-AA3,53,21 c. Serious dysfunction of any bodily organ or part.

SB70-AA3,54,2 2. With respect to a pregnant woman who is having contractions, a medical condition for which there is inadequate time to safely transfer the pregnant woman to another hospital before delivery or for which the transfer may pose a threat to the health or safety of the pregnant woman or the unborn child.

SB70-AA3,54,5 (b) “Emergency medical services,” with respect to an emergency medical condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a) (3) (C).

SB70-AA3,54,7 (c) “Independent freestanding emergency department" has the meaning given in 42 USC 300gg-111 (a) (3) (D).

SB70-AA3,54,9 (d) “Out-of-network rate” has the meaning given by the commissioner by rule or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).

SB70-AA3,54,13 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any preferred provider plan, as defined in s. 609.01 (4), that has a network of participating providers and imposes on enrollees different requirements for using providers that are not participating providers.

SB70-AA3,54,15 (f) “Recognized amount” has the meaning given by the commissioner by rule or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).

SB70-AA3,54,19 (g) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

SB70-AA3,54,22 (h) “Terminated” means the expiration or nonrenewal of a contract. “Terminated” does not include a termination of a contract for failure to meet applicable quality standards or for fraud.

SB70-AA3,55,2 (2) Emergency medical services. A defined network plan, preferred provider plan, or self-insured governmental plan that covers any benefits or services provided in an emergency department of a hospital or emergency medical services provided in an independent freestanding emergency department shall cover emergency medical services in accordance with all of the following:

SB70-AA3,55,3 (a) The plan may not require a prior authorization determination.

SB70-AA3,55,6 (b) The plan may not deny coverage on the basis of whether or not the health care provider providing the services is a participating provider or participating emergency facility.

SB70-AA3,55,9 (c) If the emergency medical services are provided to an enrollee by a provider or in a facility that is not a participating provider or participating facility, the plan complies with all of the following:

SB70-AA3,55,13 1. The emergency medical services are covered without imposing on an enrollee a requirement for prior authorization or any coverage limitation that is more restrictive than requirements or limitations that apply to emergency medical services provided by participating providers or in participating facilities.

SB70-AA3,55,17 2. Any cost-sharing requirement imposed on an enrollee for the emergency medical services is no greater than the requirements that would apply if the emergency medical services were provided by a participating provider or in a participating facility.

SB70-AA3,55,22 3. Any cost-sharing amount imposed on an enrollee for the emergency medical services is calculated as if the total amount that would have been charged for the emergency medical services if provided by a participating provider or in a participating facility is equal to the recognized amount for such services, plan or coverage, and year.

SB70-AA3,55,23 4. The plan does all of the following:

SB70-AA3,56,3 a. No later than 30 days after the participating provider or participating facility transmits to the plan the bill for emergency medical services, sends to the provider or facility an initial payment or a notice of denial of payment.

SB70-AA3,56,6 b. Pays to the participating provider or participating facility a total amount that, incorporating any initial payment under subd. 4. a., is equal to the amount by which the out-of-network rate exceeds the cost-sharing amount.

SB70-AA3,56,11 5. The plan counts any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket maximum applied by the plan in the same manner as if the cost-sharing payment was made for emergency medical services provided by a participating provider or in a participating facility.

SB70-AA3,56,17 (3) Nonparticipating provider in participating facility. For items or services other than emergency medical services that are provided to an enrollee of a defined network plan, preferred provider plan, or self-insured governmental plan by a provider who is not a participating provider but who is providing services at a participating facility, the plan shall provide coverage for the item or service in accordance with all of the following:

SB70-AA3,56,20 (a) The plan may not impose on an enrollee a cost-sharing requirement for the item or service that is greater than the cost-sharing requirement that would have been imposed if the item or service was provided by a participating provider.

SB70-AA3,56,24 (b) Any cost-sharing amount imposed on an enrollee for the item or service is calculated as if the total amount that would have been charged for the item or service if provided by a participating provider is equal to the recognized amount for such item or service, plan or coverage, and year.

SB70-AA3,57,2 (c) No later than 30 days after the provider transmits the bill for services, the plan shall send to the provider an initial payment or a notice of denial of payment.

SB70-AA3,57,6 (d) The plan shall make a total payment directly to the provider who provided the item or service to the enrollee that, added to any initial payment described under par. (c), is equal to the amount by which the out-of-network rate for the item or service exceeds the cost-sharing amount.

SB70-AA3,57,10 (e) The plan counts any cost-sharing payment made by the enrollee for the item or service toward any in-network deductible or out-of-pocket maximum applied by the plan in the same manner as if the cost-sharing payment was made for the item or service when provided by a participating provider.

SB70-AA3,57,16 (4) Charging for services by nonparticipating provider; notice and consent. (a) Except as provided in par. (c), a provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for the item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service unless the nonparticipating provider provides notice and obtains consent in accordance with all of the following:

SB70-AA3,57,19 1. The notice states that the provider is not a participating provider in the enrollee's defined network plan, preferred provider plan, or self-insured governmental plan.

SB70-AA3,57,23 2. The notice provides a good faith estimate of the amount that the nonparticipating 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.

SB70-AA3,58,3 3. The notice includes a list of the participating providers at the participating facility who would be able to provide the item or service and notification that the enrollee may be referred to one of those participating providers.

SB70-AA3,58,6 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.

SB70-AA3,58,8 5. The notice clearly states that consent is optional and that the patient may elect to seek care from an in-network provider.

SB70-AA3,58,9 6. The notice is worded in plain language.