Amendment AA3-SB70

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.

SB70-AA3,58,11 7. The notice is available in languages other than English. The commissioner shall identify languages for which the notice should be available.

SB70-AA3,58,16 8. The enrollee provides consent to the nonparticipating 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.

SB70-AA3,58,18 9. A signed copy of the consent described under subd. 8. is provided to the enrollee.

SB70-AA3,58,20 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

SB70-AA3,58,24 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.

SB70-AA3,59,3 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.

SB70-AA3,59,9 (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 an ancillary item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service, whether or not provided by a physician or non-physician practitioner, unless the commissioner specifies by rule that the provider may balance bill for the ancillary item or service, if the item or service is any of the following:

SB70-AA3,59,10 1. Related to an emergency medical service.

SB70-AA3,59,11 2. Anesthesiology.

SB70-AA3,59,12 3. Pathology.

SB70-AA3,59,13 4. Radiology.

SB70-AA3,59,14 5. Neonatology.

SB70-AA3,59,16 6. An item or service provided by an assistant surgeon, hospitalist, or intensivist.

SB70-AA3,59,17 7. A diagnostic service, including a radiology or laboratory service.

SB70-AA3,59,19 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

SB70-AA3,59,22 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.

SB70-AA3,59,25 (d) Any notice and consent provided under par. (a) may not extend to items or services furnished as a result of unforeseen, urgent medical needs that arise at the time the item or service is provided.

SB70-AA3,60,2 (e) Any consent provided under par. (a) shall be retained by the provider for no less than 7 years.

SB70-AA3,60,12 (5) Notice by provider or facility. Beginning no later than January 1, 2024, a health care provider or health care facility shall make available, including posting on a website, to enrollees in defined network plans, preferred provider plans, and self-insured governmental plans notice of the requirements on a provider or facility under sub. (4), 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.

SB70-AA3,61,4 (6) 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 (3) (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 an 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.

SB70-AA3,61,5 (7) Continuity of care. (a) In this subsection:

SB70-AA3,61,6 1. “Continuing care patient” means an individual who is any of the following:

SB70-AA3,61,8 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

SB70-AA3,61,10 b. Undergoing a course of institutional or inpatient care from a provider or facility.

SB70-AA3,61,12 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

SB70-AA3,61,14 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

SB70-AA3,61,16 e. Terminally ill and receiving treatment for the illness from a provider or facility.

SB70-AA3,61,17 2. “Serious and complex condition” means any of the following:

SB70-AA3,61,20 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.

SB70-AA3,61,23 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.

SB70-AA3,62,6 (b) If an enrollee is a continuing care patient and is obtaining items or services from a participating provider or participating facility and the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated, resulting in a loss of benefits provided under the plan, the plan shall do all of the following:

SB70-AA3,62,9 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 participating provider or participating facility under this subsection.

SB70-AA3,62,11 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

SB70-AA3,62,18 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.

SB70-AA3,62,21 (c) The provisions of s. 609.24 apply to a continuing care patient to the extent that s. 609.24 does not conflict with this subsection so as to limit the enrollee's rights under this subsection.

SB70-AA3,63,3 (8) Rule making. The commissioner may promulgate any rules necessary to implement this section, including specifying the independent dispute resolution process under sub. (6). The commissioner may promulgate rules to modify the list of those items and services for which a provider may not balance bill under sub. (4) (c). In promulgating rules under this subsection, the commissioner may consider any rules promulgated by the federal department of health and human services pursuant to the federal No Suprises Act, 42 USC 300gg-111, et seq.

SB70-AA3,38 Section 38. 609.24 (5) of the statutes is created to read:

SB70-AA3,63,7 609.24 (5) If an enrollee is a continuing care patient, as defined in s. 609.045 (7) (a), and if any of the situations described under s. 609.045 (7) (b) (intro.) applies, all of the following apply to the enrollee's defined network plan:

SB70-AA3,63,10 (a) Subsection (1) (c) shall apply to any of the participating providers providing the enrollee's course of treatment under s. 609.045 (7), including the enrollee's primary care physician.

SB70-AA3,63,13 (b) Subsection (1) (c) shall apply to lengthen the period in which benefits are provided under s. 609.045 (7) (b) 3., but shall not be applied to shorten the period in which benefits are provided under s. 609.045 (7) (b) 3.

SB70-AA3,63,15 (c) Subsection (1) (d) shall not be applied in a manner that limits the enrollee's rights under s. 609.045 (7) (b) 3.

SB70-AA3,63,18 (d) No plan may contract or arrange with a participating provider to provide notice of the termination of the participating provider's participation, pursuant to sub. (4).”.

SB70-AA3,63,19 182. Page 374, line 11: after that line insert:

SB70-AA3,63,20 “ Section 39. 609.74 of the statutes is created to read:

SB70-AA3,63,22 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

SB70-AA3,40 Section 40. 632.895 (15m) of the statutes is created to read:

SB70-AA3,63,24 632.895 (15m) Coverage of infertility services. (a) In this subsection:

SB70-AA3,64,6 1. “Diagnosis of and treatment for infertility” means any recommended procedure or medication to treat infertility at the direction of a physician that is consistent with established, published, or approved medical practices or professional guidelines from the American College of Obstetricians and Gynecologists, or its successor organization, or the American Society for Reproductive Medicine, or its successor organization.

SB70-AA3,64,8 2. “Infertility” means a disease, condition, or status characterized by any of the following:

SB70-AA3,64,13 a. The failure to establish a pregnancy or carry a pregnancy to a live birth after regular, unprotected sexual intercourse for, if the woman is under the age of 35, no longer than 12 months or, if the woman is 35 years of age or older, no longer than 6 months, including any time during those 12 months or 6 months that the woman has a pregnancy that results in a miscarriage.

SB70-AA3,64,15 b. An individual's inability to reproduce either as a single individual or with a partner without medical intervention.

SB70-AA3,64,17 c. A physician's findings based on a patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.

SB70-AA3,64,19 3. “Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town, or school district.

SB70-AA3,65,2 4. “Standard fertility preservation service” means a procedure that is consistent with established medical practices or professional guidelines published by the American Society for Reproductive Medicine or its successor organization, or the American Society of Clinical Oncology or its successor organization, for a person who has a medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.

SB70-AA3,65,9 (b) Subject to pars. (c) to (e), every disability insurance policy and self-insured health plan that provides coverage for medical or hospital expenses shall cover diagnosis of and treatment for infertility and standard fertility preservation services. Coverage required under this paragraph includes at least 4 completed oocyte retrievals with unlimited embryo transfers, in accordance with the guidelines of the American Society for Reproductive Medicine or its successor organization, and single embryo transfer may be used when recommended and medically appropriate.

SB70-AA3,65,11 (c) 1. A disability insurance policy or self-insured health plan may not do any of the following:

SB70-AA3,65,14 a. Impose any exclusions, limitations, or other restrictions on coverage required under par. (b) based on a covered individual's participation in fertility services provided by or to a 3rd party.

SB70-AA3,65,18 b. Impose any exclusion, limitation, or other restriction on coverage of medications that are required to be covered under par. (b) that are different from those imposed on any other prescription medications covered under the policy or plan.

SB70-AA3,65,25 c. Impose any exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period, or other restriction on coverage that is required under par. (b) of diagnosis of and treatment for infertility and standard fertility preservation services that is different from an exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period or other restriction imposed on benefits for services that are covered by the policy or plan and that are not related to infertility.

SB70-AA3,66,4 2. A disability insurance policy or self-insured health plan shall provide coverage required under par. (b) to any covered individual under the policy or plan, including any covered spouse or nonspouse dependent, to the same extent as other pregnancy-related benefits covered under the policy or plan.

SB70-AA3,66,10 (d) The commissioner, after consulting with the department of health services on appropriate treatment for infertility, shall promulgate any rules necessary to implement this subsection. Before the promulgation of rules, disability insurance policies and self-insured health plans are considered to comply with the coverage requirements of par. (b) if the coverage conforms to the standards of the American Society for Reproductive Medicine.

SB70-AA3,66,12 (e) This subsection does not apply to a disability insurance policy that is a health benefit plan described under s. 632.745 (11) (b).

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

SB70-AA3,66,14 (1u) Coverage of infertility services.

SB70-AA3,66,18 (a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) 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 pars. (b ) and (c).

SB70-AA3,66,23 (b) For policies and plans that have a term greater than one year and contain provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) first applies to policy or plan years beginning on January 1 of the year following the year in which the policy or plan is extended, modified, or renewed, whichever is later.

SB70-AA3,67,3 (c) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) 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-AA3,67,7 (1v) Coverage of infertility services. The treatment of ss. 609.74 and 632.895 (15m) and Section 9323 (1u) of this act take effect on the first day of the 4th month beginning after publication.”.

SB70-AA3,67,8 183. Page 374, line 11: after that line insert:

SB70-AA3,67,9 “ Section 41 . 609.713 of the statutes is created to read:

SB70-AA3,67,12 609.713 Qualified treatment trainee coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (7).

SB70-AA3,42 Section 42 . 632.87 (7) of the statutes is created to read:

SB70-AA3,67,14 632.87 (7) (a) In this subsection:

SB70-AA3,67,15 1. “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).

SB70-AA3,67,16 2. “Qualified treatment trainee” has the meaning given in s. DHS 35.03 (17m).