The bill repeals a school-based mental health consultation pilot program
created by
2019 Wisconsin Act 117. Under the current law pilot program, DHS is
required to administer a school-based mental health consultation pilot program in
Outagamie County to assist participating school-based providers in providing
enhanced care to student with mental health care needs, to provide referral support
for those students, and to provide additional services. Under current law, DHS must
conduct annual surveys of the participating school-based providers who use the
consultation pilot program and was required to submit a report on the program to
the appropriate standing committees of the legislature by August 1, 2022.
Grants for peer recovery centers
The bill allows DHS to distribute not more than $260,000 in each fiscal year to
regional recovery centers for individuals experiencing mental health and substance
abuse issues.
Psychiatric residential treatment facilities
The bill establishes a DHS certification process for psychiatric residential
treatment facilities. The bill defines a psychiatric residential treatment facility as
a non-hospital facility that provides inpatient comprehensive mental health
treatment services to individuals under the age of 21 who, due to mental illness,
substance use, or severe emotional disturbance, need treatment that can most
effectively be provided in a residential treatment facility. Psychiatric residential
treatment facilities must be certified by DHS to operate.
The bill also provides that services through a psychiatric residential treatment
facility are reimbursable under the MA program. The bill requires DHS to submit
to the federal government any request for federal approval necessary to provide the
reimbursement for services by a psychiatric residential treatment facility under the
MA program.
Under current law, DHS is required to award grants for certain community
programs. The bill allows DHS to distribute up to $1,790,000 each fiscal year to
support psychiatric residential treatment facilities.
COVID-19 health care workforce pilot project
The bill requires DHS to distribute $621,000 in fiscal year 2024-25 to support
a pilot project in Dane County relating to the impact of the COVID-19 pandemic on
the health care workforce.
Suicide prevention program
The bill requires DHS to implement a suicide prevention program, coordinate
suicide prevention activities with other state agencies, administer grant programs
involving suicide prevention, and perform various other functions specified in the
bill to promote efforts to prevent suicide. The bill also specifically requires DHS to
award grants to organizations or coalitions of organizations, including cities,
villages, towns, counties, and federally recognized American Indian tribes or bands
in this state, for 1) training staff at a firearm retailer or firearm range on how to
recognize a person that may be considering suicide; 2) providing suicide prevention
materials for distribution at a firearm retailer or firearm range; or 3) providing
voluntary, temporary firearm storage. A grant recipient must contribute matching
funds or in-kind services having a value equal to at least 20 percent of the grant
amount. The bill specifies that DHS may award up to $500,000 in grants for the
suicide prevention program each fiscal year, including up to $75,000 per fiscal year
for the grants related to preventing suicide by firearm.
988 Suicide and Crisis Lifeline grants
The bill requires DHS to awards grants to organizations that provide crisis
intervention services and crisis care coordination to individuals who contact the
national 988 Suicide and Crisis Lifeline from anywhere within this state. Currently,
DHS partners with Wisconsin Lifeline to provide statewide 988 crisis hotline
services.
Stimulant prevention and treatment response programs
Under current law, DHS awards grants for certain community programs. The
bill allows DHS to distribute up to $1,644,000 in each fiscal year to support stimulant
use prevention and treatment programs and services.
Grants for youth crisis stabilization facilities
The bill requires DHS to award grants to organizations to develop and support
youth crisis stabilization facilities. Under current law, a youth crisis stabilization
facility is a treatment facility with a maximum of eight beds that admits minors to
prevent or de-escalate a mental health crisis and avoid admission to a more
restrictive setting. Youth crisis stabilization facilities must be certified by DHS to
operate.
Peer run respite centers
The bill makes changes to how DHS may distribute grant moneys to regional
peer run respite centers for individuals with mental health and substance abuse
concerns. Under current law, DHS may distribute not more than $1,200,000 in each
fiscal year for this purpose and may use any of three appropriations to fund the
grants. The bill removes the limitation on the amount that DHS may annually
distribute and requires DHS to use only one appropriation to fund the grants.
Early intervention services for children with lead in their blood
Under current law, DHS implements a statewide program, referred to as the
Birth to 3 program, that provides early intervention services for children aged three
and under who are developmentally delayed or are diagnosed as having a condition
that is likely to result in significantly delayed development. The bill ensures that
children with a concentration of lead in their blood of at least 3.5 micrograms per 100
milliliters of blood are eligible for services under the Birth to 3 program. The bill also
allows DHS to develop a methodology to allocate funding for early intervention
services across county programs.
Deaf, Hard of Hearing, and Deaf-Blind Behavioral Health Treatment
Center
The bill allows DHS, as part of the grants DHS is required to award for
community programs, to distribute up to $1,936,000 in each fiscal year starting with
fiscal year 2024-25 to a statewide provider of behavioral health treatment services
for individuals who are deaf, hard of hearing, or deaf-blind.
Service dog training grants
The bill requires DHS to annually award grants to organizations that train
service dogs for the purpose of assisting providers in attaining accreditation specific
to post-traumatic stress disorder training from Assistance Dog International.
General health and human services
Spinal cord injury research grants and symposia
The bill requires DHS to establish a program to award grants to persons in this
state for research into spinal cord injuries. The grants must support research on new
and innovative treatments and rehabilitative efforts for the functional improvement
of people with spinal cord injuries. Research topics may include pharmaceutical,
medical device, brain stimulus, and rehabilitative approaches and techniques. DHS
must make annual reports to the legislature about the grants. The bill also allows
DHS to hold symposia every two years for grant recipients to present their research
findings.
The bill also requires DHS to appoint a Spinal Cord Injury Council with one
member representing the UW School of Medicine and Public Health, one member
representing the Medical College of Wisconsin, and the following members: 1) a
person with a spinal cord injury; 2) a family member of a person with a spinal cord
injury; 3) a veteran with a spinal cord injury; 4) a physician specializing in the
treatment of spinal cord injuries; 5) a neurosurgery researcher; and 6) a researcher
employed by the Veterans Health Administration of the U.S. Department of Veterans
Affairs. If DHS is unable to appoint any of the foregoing members, the bill allows
DHS to appoint, in lieu of that member, a member representing the general public.
Members of the council have two-year terms. The bill requires the council to develop
criteria for DHS to evaluate and award grants, review and make recommendations
on grant applications, and perform other duties specified by DHS. Council members
must make written disclosures of financial interests in organizations that the council
recommends for grants.
Making references in the statutes gender neutral
The bill recognizes same-sex marriage by making references in the statutes to
spouses gender-neutral, with the intent of harmonizing the statutes with the
holding of the U.S. Supreme Court in Obergefell v. Hodges, 135 S. Ct. 2584, 192 L.
Ed. 2d 609 (2015), which recognizes that same-sex couples have a fundamental
constitutional right to marriage. The bill also recognizes legal parentage for
same-sex couples under certain circumstances and adopts gender-neutral
parentage terminology.
The bill provides that marriage may be contracted between persons of the same
sex and confers the same rights and responsibilities on married persons of the same
sex that married persons of different sexes have under current law. The bill defines
“spouse" as a person who is legally married to another person of the same sex or a
different sex and replaces each reference to “husband" or “wife" in current law with
“spouse." The bill makes applicable to married persons of the same sex all provisions
under current law that apply to married persons of different sexes. These provisions
relate to such diverse areas of the law as income tax, marital property, inheritance
rights, divorce, child and spousal support, insurance coverage, family and spousal
recreational licenses, consent to conduct an autopsy, domestic abuse, and eligibility
for various types of benefits, such as retirement or death benefits and medical
assistance.
In addition to making statutory references to spouses gender-neutral, the bill
specifies ways in which married couples of the same sex may be the legal parents of
a child and, with some exceptions, makes current references in the statutes to
“mother" and “father," and related terms, gender-neutral.
Under current law, all of the following may adopt a child: a husband and wife
jointly, a husband or wife whose spouse is the parent of the child, and an unmarried
adult. Because the bill makes references in the statutes to spouses gender-neutral,
same-sex spouses jointly may adopt a child and become the legal parents of the child,
and a same-sex spouse of a person who is the parent of a minor child may adopt the
child and become the legal parent of his or her spouse's child.
Under current law, if a married woman is artificially inseminated under the
supervision of a physician with semen donated by a man who is not her husband and
the woman's husband consents in writing to the artificial insemination of his wife,
the husband is the natural father of any child conceived. Under the bill, one spouse
may also consent to the artificial insemination of his or her spouse and is the natural
parent of the child conceived. The artificial insemination is not required to take place
under the supervision of a physician, but, if it does not, the semen used for the
insemination must have been obtained from a sperm bank.
Under current law, a man is presumed to be the father of a child if he and the
child's natural mother 1) were married to each other when the child was conceived
or born or 2) married each other after the child was born but had a relationship with
each other when the child was conceived and no other man has been adjudicated to
be the father or is presumed to be the father because the man was married to the
mother when the child was conceived or born. The paternity presumption may be
rebutted in a legal action or proceeding by the results of a genetic test showing that
the statistical probability of another man's parentage is 99.0 percent or higher. The
bill expands this presumption into a parentage presumption, so that a person is
presumed to be the natural parent of a child if he or she 1) was married to the child's
established natural parent when the child was conceived or born or 2) married the
child's established natural parent after the child was born but had a relationship
with the established natural parent when the child was conceived and no person has
been adjudicated to be the father and no other person is presumed to be the child's
parent because he or she was married to the mother when the child was conceived
or born. The parentage presumption may still be rebutted by the results of a genetic
test showing that the statistical probability of another person's parentage is 99.0
percent or higher. Expanding on current law, the bill allows for a paternity action
to be brought for the purpose of rebutting the parentage presumption, regardless of
whether that presumption applies to a male or female spouse.
Current law provides that a mother and a man may sign a statement
acknowledging paternity and file it with the state registrar. If the state registrar has
received such a statement, the man is presumed to be the father of the child. Under
current law, either person who has signed a statement acknowledging paternity may
rescind the statement before an order is filed in an action affecting the family
concerning the child or within 60 days after the statement is filed, whichever occurs
first. Under current law, a man who has filed a statement acknowledging paternity
that is not rescinded within the time period is conclusively determined to be the
father of the child. The bill provides that two individuals may sign a statement
acknowledging parentage and file it with the state registrar. If the state registrar
has received such a statement, the individuals who have signed the statement are
presumed to be the parents of the child. Under the bill, a statement acknowledging
parentage that is not rescinded conclusively establishes parentage with regard to the
individual who did not give birth to the child and who signed the statement.
The bill defines “natural parent" as a parent of a child who is not an adoptive
parent, whether the parent is biologically related to the child or not. Thus, a person
who is a biological parent, a parent by consenting to the artificial insemination of his
or her spouse, or a parent under the parentage presumption is a natural parent of
a child. The definition applies throughout the statutes wherever the term “natural
parent" is used. In addition, the bill expands some references in the statutes to
“biological parent" by changing the reference to “natural parent."
Gender neutral references on birth certificates
Generally, the bill substitutes the term “spouse" for “husband" in the provisions
of the statutes relating to birth certificates and enters the spouse, instead of the
husband, of the person who has given birth on the birth certificate at times when a
husband would currently be entered on a birth certificate. The name of the person
who has given birth is entered on a birth certificate when the person gives birth to
a child, and current law specifies when another name should be entered on the birth
certificate. Current law requires that if a birth mother is married at any time from
the conception to the birth of a child, then her husband's name is entered on the birth
certificate as the legal father of the child. Under the bill, if a person who gives birth
is married at any time from the conception to the birth of the child, then that person's
spouse's name is entered as a legal parent of the child. The bill also specifies that,
in the instance that a second parent's name is initially omitted from the birth
certificate, if the state registrar receives a signed acknowledgement of parentage by
persons presumed to be parents because the two persons married after the birth of
the child, the two persons had a relationship during the time the child was conceived,
no person is adjudicated to be the father, and no other person is presumed to be the
parent, then the state registrar must enter the name of the spouse of the person who
gave birth as a parent on the birth certificate.
Transfer of security operations at Wisconsin Resource Center
The bill transfers security operations at the Wisconsin Resource Center from
DOC to DHS. The transfer includes the transfer of assets, liabilities, position
authorizations and the incumbent employees holding those positions, tangible
personal property, contracts, and any currently pending matters.
Electrocardiogram screening pilot project for middle school and high
school athletes in Milwaukee and Waukesha Counties
The bill directs DHS to develop a pilot program to provide electrocardiogram
screenings for participants in middle school and high school athletics programs in
Milwaukee and Waukesha Counties. DHS is required to award $4,172,000 in grants
in fiscal year 2024-25 to local health departments to implement the program. The
bill specifies that participation in the program by participants in middle school and
high school athletics programs must be optional.
State long-term care ombudsman
Under current law, the Board on Aging and Long-term Care appoints an
executive director of the Office of Long-term Care Ombudsman. The bill requires
the executive director to employ the state long-term care ombudsman within the
classified service and allows the state long-term care ombudsman to delegate
operation of the office to staff.
housing
Low-income housing tax credit
Under current law, WHEDA may certify a person to claim, for a period of up to
six years, a state tax credit if the person has an ownership interest in a low-income
housing project in Wisconsin and qualifies for the federal low-income housing tax
credit program. The bill increases the period for which the credit may be claimed
from six years to 10 years and increases the amount of credits that WHEDA may
annually certify from $42,000,000 to $100,000,000. The bill also requires that the
project be allocated the federal credit and financed with tax-exempt bonds that are
not subject to the federal credit's volume cap—as opposed to
any tax-exempt bonds,
as required under current law—and allows WHEDA to waive these requirements to
the extent that WHEDA anticipates that a sufficient tax-exempt private activity
bond volume cap under federal law will not be available to finance low-income
housing projects in any year.
Capital reserve fund bonding limit
Under current law, WHEDA issues notes and bonds for most WHEDA
programs, including housing programs for individuals and families of low or
moderate income. Current law prohibits WHEDA from issuing notes and bonds that
are secured by a capital reserve fund if the total aggregate outstanding principal
amount would exceed $800,000,000. The bill increases that limit to $1,200,000,000.
Workforce housing rehabilitation fund
Under current law, as created by
2021 Wisconsin Act 221, WHEDA may make
workforce housing rehabilitation loans to eligible applicants for the cost of certain
kinds of rehabilitation to the applicant's home, subject to certain requirements.
Currently, WHEDA makes those loans from WHEDA's housing rehabilitation loan
fund, which preexisted the creation of the workforce housing rehabilitation loan
program in Act 221.
The bill establishes a workforce housing rehabilitation fund under the
jurisdiction and control of WHEDA for the purpose of providing workforce housing
rehabilitation loans. At WHEDA's discretion, the workforce housing rehabilitation
fund may additionally be used for purposes of marketing WHEDA's programs and
services to the public. The fund consists in part of general purpose revenues
transferred to the fund.
The bill also makes certain changes to the workforce housing rehabilitation
loan program, including requiring that an eligible residence be the loan applicant's
primary residence and authorizing WHEDA to defer or forgive the payment of a
workforce housing rehabilitation loan under certain criteria established by WHEDA.
Rental housing safety grants
The bill establishes a pilot program under which DOA must award one or more
grants to a first class city (presently only Milwaukee) for activities that support the
improvement of rental housing safety in the city, including the enhancement or
creation of a property inspection program and the development and launch of a
searchable online database that discloses the history of rental properties within the
city. The bill authorizes DOA to establish program guidelines for the grant program
under this subsection. Under the bill, the grant program sunsets on June 30, 2025.
Rental assistance grants for homeless veterans
The bill requires DOA to award grants to each continuum of care organization
in this state for the purpose of providing tenant-based rental assistance to homeless
veterans. A continuum of care organization is an organization designated by the
federal Department of Housing and Urban Development that provides funding and
services to alleviate homelessness.
Homeless case management services grants
Under current law, DOA may award up to 10 grants of up to $50,000 each year
to shelter facilities for case management services provided to homeless families. The
bill eliminates the limit on the number of grants that may be awarded and raises the
grant limit to $75,000.
Whole-home upgrade grants
The bill establishes a pilot program under which DOA must award one or more
grants to the Walnut Way Conservation Corporation and Elevate, Inc., for the
purpose of funding home improvements in low-income households in a first class city
(presently only Milwaukee). The grants must have one or more of the following goals:
1) reducing carbon emissions, 2) reducing energy burdens, 3) creating cost savings,
or 4) creating healthier living environments.
The bill authorizes DOA to establish eligibility requirements and other
program guidelines for the grant program. Under the bill, the grant program sunsets
on July 1, 2025.
Affordable housing grants
The bill requires DOA to award grants to municipalities for the purpose of
increasing the availability of affordable workforce housing within the
municipalities.
Water utility assistance program for low-income households
The bill creates a water utility assistance program for low-income households
that is administered by DOA. Under the program, low-income households may
apply for assistance from the state to help pay the cost of their water utility bills.
Although the program is administered by DOA, DOA may contract with a county
department or other local governmental agency or a private nonprofit organization
to process applications and make assistance payments. DOA must establish a
payments schedule for the program. If the number of household applicants exceeds
the number anticipated to apply, payments to households may be reduced and DOA
may suspend additional applications for assistance. Under the bill, a household
eligible for water utility assistance may also be eligible for a crisis assistance
payment if the household is experiencing or at risk of experiencing a water
utility-related emergency, as defined by DOA.
Municipal home rehabilitation grants
The bill requires DOA to award grants to municipalities to fund initiatives to
rehabilitate and restore blighted residential properties within the municipality. The
bill authorizes DOA to establish eligibility requirements and other program
guidelines for the grant program.
Housing quality standards grants
The bill requires DOA to award grants to owners of rental housing units in
Wisconsin for purposes of satisfying applicable housing quality standards.
insurance
Coverage of individuals with preexisting conditions and other insurance
market regulations
The bill requires certain health plans to guarantee access to coverage; prohibits
plans from imposing preexisting condition exclusions; prohibits plans from setting
premiums or cost-sharing amounts based on health status-related factors; prohibits
plans from setting lifetime or annual limits on benefits; requires plans to cover
certain essential health benefits; requires coverage of certain preventive services by
plans without a cost-sharing contribution by an enrollee; sets a maximum annual
amount of cost sharing for enrollees; and designates risk pool, medical loss ratio, and
actuarial value requirements.
The bill requires every individual health insurance policy, known in the bill as
a health benefit plan, to accept every individual who applies for coverage and
requires every group health insurance policy to accept every employer that applies
for coverage, regardless of the individual's or any employee's sexual orientation or
gender identity and regardless of whether the individual or any employee has a
preexisting condition. The bill allows health benefit plans to restrict enrollment in
coverage to open or special enrollment periods and requires the commissioner of
insurance to establish a statewide open enrollment period of no shorter than 30 days
for every individual health benefit plan. The bill prohibits a group health insurance
policy, including a self-insured governmental health plan, from imposing a
preexisting condition exclusion. The bill also prohibits an individual health
insurance policy from reducing or denying a claim or loss incurred or disability
commencing under the policy on the ground that a disease or physical condition
existed prior to the effective date of coverage.
A health benefit plan offered on the individual or small employer market or a
self-insured governmental health plan may not vary premium rates for a specific
plan except on the basis of whether the plan covers an individual or family, area in
the state, age, and tobacco use as specified in the bill. An individual health benefit
plan or self-insured health plan is prohibited under the bill from establishing rules
for the eligibility of any individual to enroll based on health status-related factors,
which are specified in the bill. A self-insured health plan or an insurer offering an
individual health benefit plan is also prohibited from requiring an enrollee to pay a
greater premium, contribution, deductible, copayment, or coinsurance amount than
is required of a similarly situated enrollee based on a health status-related factor.
Current state law prohibits group health benefit plans from establishing rules of
eligibility or requiring greater premium or contribution amounts based on a health
status-related factor. The bill adds to these current law requirements for group
health benefit plans that the plan may not require a greater deductible, copayment,
or coinsurance amount based on a health status-related factor.
Under the bill, an individual or group health benefit plan or a self-insured
governmental health plan may not establish lifetime or annual limits on the dollar
value of benefits for an enrollee or a dependent of an enrollee under the plan. The
bill specifies a maximum amount of cost sharing that a plan may impose as the
amount calculated under the federal Patient Protection and Affordable Care Act
(ACA).
The bill requires individual and small employer plans to have either a single
statewide risk pool for the individual market and a single pool for the small employer
market or a single statewide risk pool for a combination of the individual and small
employer markets. The bill requires individual and small employer plans to have a
medical loss ratio of at least 80 percent and larger group plans to have a medical loss
ratio of at least 85 percent. The medical loss ratio is the proportion of premium
revenues that the plan spends on clinical services and quality improvement. The bill
also requires individual and small employer plans to 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. An actuarial value
of 60 percent corresponds to a bronze tier plan under the ACA.
Health insurance policies are referred to as disability insurance policies in the
bill, and a self-insured governmental health plan is a self-funded health plan of the
state or a county, city, village, town, or school district. The bill requires certain health
insurance policies and governmental self-insured health plans to cover essential
health benefits that will be specified by the commissioner of insurance by rule. The
bill specifies a list of requirements that the commissioner must follow when
establishing the essential health benefits, including certain limitations on cost
sharing and the following general categories of benefits, items, or services in which
the commissioner must require coverage: ambulatory patient services, emergency
services, hospitalization, maternity and newborn care, mental health and substance
use disorder services, prescription drugs, rehabilitative and habilitative services
and devices, laboratory services, preventive and wellness services and chronic
disease management, and pediatric services. If an essential health benefit specified
by the commissioner is also subject to its own mandated coverage requirement, the
bill requires the disability insurance policy or self-insured health plan to provide
coverage under whichever requirement provides the insured or plan participant with
more comprehensive coverage.
The bill requires health insurance policies and governmental self-insured
health plans to cover certain preventive services and to provide coverage of those
preventive services without subjecting that coverage to deductibles, copayments, or
coinsurance. The preventive services for which coverage is required are specified in
the bill. The bill also specifies certain instances when cost-sharing amounts may be
charged for an office visit associated with a preventive service.
Balance billing for emergency medical services and other items and services
The bill requires defined network plans, such as health maintenance
organizations, and certain preferred provider plans and self-insured governmental
plans that cover benefits or services provided in either an emergency department of
a hospital or independent freestanding emergency department to cover emergency
medical services without requiring a prior authorization determination and without
regard to whether the health care provider providing the emergency medical services
is a participating provider or facility. If the emergency medical services for which
coverage is required are provided by a nonparticipating provider, the plan must 1)
not impose a prior authorization requirement or other limitation that is more
restrictive than if the service was provided by a participating provider; 2) not impose
cost sharing on an enrollee that is greater than the cost sharing required if the
service was provided by a participating provider; 3) calculate the cost-sharing
amount to be equal to the recognized amount specified under federal law; 4) provide,
within 30 days of the provider's or facility's bill, an initial payment or denial notice
to the provider or facility and then pay a total amount to the provider or facility that
is equal to the amount by which an out-of-network rate exceeds the amount it
received in cost sharing from the enrollee; and 5) count any cost-sharing payment
made by the enrollee for the emergency medical services toward any in-network
deductible or out-of-pocket maximum as if the cost-sharing payment was made for
services provided by a participating provider or facility.
For coverage of an item or service that is provided by a nonparticipating
provider in a participating facility, a plan must 1) not impose 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; 2) calculate the cost-sharing amount to be equal to the
recognized amount specified under federal law; 3) provide, within 30 days of the
provider's bill, an initial payment or denial notice to the provider and then pay a total
amount to the provider that is equal to the amount by which the out-of-network rate
exceeds the amount it received in cost sharing from the enrollee; and 4) count any
cost-sharing payment made by the enrollee for the items or services toward any
in-network deductible or out-of-pocket maximum as if the cost-sharing payment
was made for items or services provided by a participating provider. A
nonparticipating provider providing an item or service in a participating facility may
not bill or hold liable an enrollee for more than the cost-sharing amount unless the
provider provides notice and obtains consent as described in the bill. However, if the
nonparticipating provider is providing an ancillary item or service that is specified
in the bill, and the commissioner of insurance has not specifically allowed balance
billing for that item or service by rule, the nonparticipating provider providing the
ancillary item or service in a participating facility may not bill or hold liable an
enrollee for more than the cost-sharing amount.
Under the bill, a provider or facility that is entitled to a payment for an
emergency medical service or other item or service may initiate open negotiations
with the defined network plan, preferred provider plan, or self-insured
governmental health plan to determine the amount of payment. If the open
negotiation period terminates without determination of the payment amount, the
provider, facility, or plan may initiate the independent dispute resolution process as
specified by the commissioner of insurance.
If an enrollee of a plan is a continuing care patient, as defined in the bill, and
is obtaining services from a participating provider or facility, and the contract is
terminated because of a change in the terms of the participation of the provider or
facility in the plan or the contract is terminated resulting in a loss of benefits under
the plan, the plan must notify the enrollee of the enrollee's right to elect to continue
transitional care, provide the enrollee an opportunity to notify the plan of the need
for transitional care, and allow the enrollee to continue to have the benefits provided
under the plan under the same terms and conditions as would have applied without
the termination until either 90 days after the termination notice date or the date on
which the enrollee is no longer a continuing care patient, whichever is earlier.
Fiduciary duty of pharmacy benefit managers
