AB43: Bill Text

AB43,,8960 4. If multiple well-woman visits described under par. (b) 47. are required to fulfill all necessary preventive services and are in accordance with clinical recommendations, the disability insurance policy or self-insured health plan may not apply a deductible to or impose a copayment or coinsurance on any of those well-woman visits.

AB43,3101 Section 3101. 632.895 (14) (a) 1. i. and j. of the statutes are amended to read:

AB43,,8962 632.895 (14) (a) 1. i. Hepatitis A and B.

AB43,,8963 j. Varicella and herpes zoster.

AB43,3102 Section 3102. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:

AB43,,8965 632.895 (14) (a) 1. k. Human papillomavirus.

AB43,,8966 L. Meningococcal meningitis.

AB43,,8967 m. Pneumococcal pneumonia.

AB43,,8968 n. Influenza.

AB43,,8969 o. Rotavirus.

AB43,3103 Section 3103. 632.895 (14) (b) of the statutes is amended to read:

AB43,,8971 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.

AB43,3104 Section 3104. 632.895 (14) (c) of the statutes is amended to read:

AB43,,8973 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.

AB43,3105 Section 3105. 632.895 (14) (d) 3. of the statutes is amended to read:

AB43,,8975 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).

AB43,3106 Section 3106. 632.895 (14m) of the statutes is created to read:

AB43,,8977 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB43,,8978 (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).

AB43,,8979 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB43,,8980 1. Include benefits, items, and services in, at least, all of the following categories:

AB43,,8981 a. Ambulatory patient services.

AB43,,8982 b. Emergency services.

AB43,,8983 c. Hospitalization.

AB43,,8984 d. Maternity and newborn care.

AB43,,8985 e. Mental health and substance use disorder services, including behavioral health treatment.

AB43,,8986 f. Prescription drugs.

AB43,,8987 g. Rehabilitative and habilitative services and devices.

AB43,,8988 h. Laboratory services.

AB43,,8989 i. Preventive and wellness services and chronic disease management.

AB43,,8990 j. Pediatric services, including oral and vision care.

AB43,,8991 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.

AB43,,8992 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.

AB43,,8993 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB43,,8994 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.

AB43,,8995 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.

AB43,,8996 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.

AB43,,8997 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.

AB43,,8998 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.

AB43,,8999 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB43,,9000 (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.

AB43,,9001 (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.

AB43,,9002 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

AB43,3107 Section 3107. 632.895 (15m) of the statutes is created to read:

AB43,,9004 632.895 (15m) Coverage of infertility services. (a) In this subsection:

AB43,,9005 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.

AB43,,9006 2. “Infertility” means a disease, condition, or status characterized by any of the following:

AB43,,9007 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.

AB43,,9008 b. An individual’s inability to reproduce either as a single individual or with a partner without medical intervention.

AB43,,9009 c. A physician’s findings based on a patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.

AB43,,9010 3. “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

AB43,,9011 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.

AB43,,9012 (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.

AB43,,9013 (c) 1. A disability insurance policy or self-insured health plan may not do any of the following:

AB43,,9014 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.

AB43,,9015 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.

AB43,,9016 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.

AB43,,9017 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.

AB43,,9018 (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.

AB43,,9019 (e) This subsection does not apply to a disability insurance policy that is a health benefit plan described under s. 632.745 (11) (b).

AB43,3108 Section 3108. 632.895 (16m) (b) of the statutes is amended to read:

AB43,,9021 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.

AB43,3109 Section 3109. 632.895 (17) (b) 2. of the statutes is amended to read:

AB43,,9023 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.

AB43,3110 Section 3110. 632.895 (17) (c) of the statutes is amended to read:

AB43,,9025 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.

AB43,3111 Section 3111. 632.897 (11) (a) of the statutes is amended to read:

AB43,,9027 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.

AB43,3112 Section 3112. 655.001 (1) of the statutes is renumbered 655.001 (1r).

AB43,3113 Section 3113. 655.001 (1g) of the statutes is created to read:

AB43,,9030 655.001 (1g) “Advanced practice registered nurse” means an individual who is licensed under s. 441.09, who has qualified to practice independently in his or her recognized role under s. 441.09 (3m) (b), and who practices advanced practice registered nursing, as defined under s. 441.001 (1c), outside of a collaborative relationship with a physician or dentist, as described under s. 441.09 (3m) (a) 1., or other employment relationship. “Advanced practice registered nurse” does not include an individual who only engages in the practice of a certified nurse-midwife, as defined under s. 441.001 (3c).

AB43,3114 Section 3114. 655.001 (7t) of the statutes is amended to read:

AB43,,9032 655.001 (7t) “Health care practitioner” means a health care professional, as defined in s. 180.1901 (1m), who is an employee of a health care provider described in s. 655.002 (1) (d), (e), (em), or (f) and who has the authority to provide health care services that are not in collaboration with a physician under s. 441.15 (2) (b) or under the direction and supervision of a physician or nurse anesthetist advanced practice registered nurse.

AB43,3115 Section 3115. 655.001 (9) of the statutes is repealed.

AB43,3116 Section 3116. 655.002 (1) (a) of the statutes is amended to read:

AB43,,9035 655.002 (1) (a) A physician or a nurse anesthetist an advanced practice registered nurse for whom this state is a principal place of practice and who practices his or her profession in this state more than 240 hours in a fiscal year.

AB43,3117 Section 3117. 655.002 (1) (b) of the statutes is amended to read:

AB43,,9037 655.002 (1) (b) A physician or a nurse anesthetist an advanced practice registered nurse for whom Michigan is a principal place of practice, if all of the following apply:

AB43,,9038 1. The physician or nurse anesthetist advanced practice registered nurse is a resident of this state.

AB43,,9039 2. The physician or nurse anesthetist advanced practice registered nurse practices his or her profession in this state or in Michigan or a combination of both more than 240 hours in a fiscal year.

AB43,,9040 3. The physician or nurse anesthetist advanced practice registered nurse performs more procedures in a Michigan hospital than in any other hospital. In this subdivision, “Michigan hospital” means a hospital located in Michigan that is an affiliate of a corporation organized under the laws of this state that maintains its principal office and a hospital in this state.

AB43,3118 Section 3118. 655.002 (1) (c) of the statutes is amended to read:

AB43,,9042 655.002 (1) (c) A physician or nurse anesthetist an advanced practice registered nurse who is exempt under s. 655.003 (1) or (3), but who practices his or her profession outside the scope of the exemption and who fulfills the requirements under par. (a) in relation to that practice outside the scope of the exemption. For a physician or a nurse anesthetist an advanced practice registered nurse who is subject to this chapter under this paragraph, this chapter applies only to claims arising out of practice that is outside the scope of the exemption under s. 655.003 (1) or (3).

AB43,3119 Section 3119. 655.002 (1) (d) of the statutes is amended to read:

AB43,,9044 655.002 (1) (d) A partnership comprised of physicians or nurse anesthetists advanced practice registered nurses and organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists advanced practice registered nurses.

AB43,3120 Section 3120. 655.002 (1) (e) of the statutes is amended to read:

AB43,,9046 655.002 (1) (e) A corporation organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists advanced practice registered nurses.

AB43,3121 Section 3121. 655.002 (1) (em) of the statutes is amended to read:

AB43,,9048 655.002 (1) (em) Any organization or enterprise not specified under par. (d) or (e) that is organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists advanced practice registered nurses.