AB43: Bill Text

AB43,,8581 2. “Serious and complex condition” means any of the following:

AB43,,8582 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.

AB43,,8583 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.

AB43,,8584 (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:

AB43,,8585 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.

AB43,,8586 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB43,,8587 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.

AB43,,8588 (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.

AB43,,8589 (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.

AB43,3051 Section 3051. 609.20 (3) of the statutes is created to read:

AB43,,8591 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).

AB43,3052 Section 3052. 609.24 (5) of the statutes is created to read:

AB43,,8593 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:

AB43,,8594 (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.

AB43,,8595 (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.

AB43,,8596 (c) Subsection (1) (d) shall not be applied in a manner that limits the enrollee’s rights under s. 609.045 (7) (b) 3.

AB43,,8597 (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).

AB43,3053 Section 3053. 609.712 of the statutes is created to read:

AB43,,8599 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB43,3054 Section 3054. 609.713 of the statutes is created to read:

AB43,,8601 609.713 Qualified treatment trainee coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (7).

AB43,3055 Section 3055. 609.714 of the statutes is created to read:

AB43,,8603 609.714 Substance abuse counselor coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (8).

AB43,3056 Section 3056. 609.719 of the statutes is created to read:

AB43,,8605 609.719 Coverage for telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB43,3057 Section 3057. 609.74 of the statutes is created to read:

AB43,,8607 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

AB43,3058 Section 3058. 609.83 of the statutes is amended to read:

AB43,,8609 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).

****Note: This is reconciled s. 609.83. This Section has been affected by drafts with the following LRB numbers: -1152/P1 and -1157/P1.

AB43,3059 Section 3059. 609.847 of the statutes is created to read:

AB43,,8611 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.

AB43,3060 Section 3060. 611.11 (4) (a) of the statutes is amended to read:

AB43,,8613 611.11 (4) (a) In this subsection, “municipality” has the meaning given in s. 345.05 (1) (c), but also includes any transit authority created under s. 66.1039.

AB43,3061 Section 3061. 625.12 (1) (a) of the statutes is amended to read:

AB43,,8615 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB43,3062 Section 3062. 625.12 (1) (e) of the statutes is amended to read:

AB43,,8617 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB43,3063 Section 3063. 625.12 (2) of the statutes is amended to read:

AB43,,8619 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).

AB43,3064 Section 3064. 625.15 (1) of the statutes is amended to read:

AB43,,8621 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.

AB43,3065 Section 3065. 628.34 (3) (a) of the statutes is amended to read:

AB43,,8623 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 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.

****Note: This is reconciled s. 628.34 (3) (a). This Section has been affected by drafts with the following LRB numbers: -1153/P1 and -1154/P1.

AB43,3066 Section 3066. 628.495 of the statutes is created to read:

AB43,,8625 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB43,,8626 (2) License required. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmacy benefit management broker or consultant or any other individual who procures the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

AB43,,8627 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

AB43,3067 Section 3067. 632.35 of the statutes is amended to read:

AB43,,8629 632.35 Prohibited rejection, cancellation and nonrenewal. No insurer may cancel or refuse to issue or renew an automobile insurance policy wholly or partially because of one or more of the following characteristics of any person: age, sex, residence, race, color, creed, religion, national origin, ancestry, marital status or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).

AB43,3068 Section 3068. 632.728 of the statutes is created to read:

AB43,,8631 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB43,,8632 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB43,,8633 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB43,,8634 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB43,,8635 (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.

AB43,,8636 (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.

AB43,,8637 (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:

AB43,,8638 1. Health status.

AB43,,8639 2. Medical condition, including both physical and mental illnesses.

AB43,,8640 3. Claims experience.

AB43,,8641 4. Receipt of health care.

AB43,,8642 5. Medical history.

AB43,,8643 6. Genetic information.

AB43,,8644 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB43,,8645 8. Disability.

AB43,,8646 (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.

AB43,,8647 (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.

AB43,,8648 (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:

AB43,,8649 (a) Whether the policy or plan covers an individual or a family.

AB43,,8650 (b) Rating area in the state, as established by the commissioner.

AB43,,8651 (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.

AB43,,8652 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB43,,8653 (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.

AB43,,8654 (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:

AB43,,8655 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB43,,8656 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB43,,8657 (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.

AB43,,8658 (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.

AB43,,8659 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

AB43,,8660 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB43,,8661 (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.

AB43,3069 Section 3069. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB43,,8663 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant’s or beneficiary’s enrollment date under the plan on a participant or beneficiary under the plan.

AB43,3070 Section 3070. 632.746 (1) (b) of the statutes is repealed.

AB43,3071 Section 3071. 632.746 (2) (a) of the statutes is amended to read:

AB43,,8666 632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

AB43,3072 Section 3072. 632.746 (2) (c), (d) and (e) of the statutes are repealed.