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
The bill imposes fiduciary and disclosure requirements on pharmacy benefit managers. Pharmacy benefit managers contract with health plans that provide prescription drug benefits to administer those benefits for the plans. Pharmacy benefit managers also have contracts with pharmacies and pay the pharmacies for providing the drugs to the plan beneficiaries.
The bill provides that a pharmacy benefit manager owes a fiduciary duty to a plan sponsor. The bill also requires that a pharmacy benefit manager annually disclose all of the following information to the plan sponsor:
1. The indirect profit received by the pharmacy benefit manager from owning a pharmacy or service provider.
2. Any payments made to a consultant or broker who works on behalf of the plan sponsor.
3. From the amounts received from drug manufacturers, the amounts retained by the pharmacy benefit manager that are related to the plan sponsor’s claims or bona fide service fees.
4. The amounts received from network pharmacies and the amount retained by the pharmacy benefit manager.
Licensure of pharmacy benefit management brokers and consultants
The bill requires an individual who is acting 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 to be licensed by OCI. The bill allows OCI to promulgate administrative rules to establish criteria, procedures, and fees for licensure. A pharmacy benefit manager, as defined under current law, is an entity that contracts to administer or manage prescription drug benefits on behalf of an insurer or other entity that provides prescription drug benefits.
Prescription drug affordability review board
The bill creates a prescription drug affordability review board, whose purpose is to protect Wisconsin residents and other stakeholders from the high costs of prescription drugs. The board consists of the commissioner of insurance and the following members, all of whom are appointed by the governor for four-year terms:
1. Two members who represent the pharmaceutical drug industry, at least one of whom is a licensed pharmacist.
2. Two members who represent the health insurance industry.
3. Two members who represent the health care industry, at least one of whom is a licensed practitioner.
4. Two members who represent the interests of the public.
The bill requires the board to meet in open session at least four times per year to review prescription drug pricing information. The board must provide at least two weeks’ public notice of its meetings, make the meeting’s materials publicly available at least one week prior to meeting, and provide the opportunity for public comment. The bill imposes conflict of interest requirements for the board relating to recusal and public disclosure of certain conflicts. The bill directs the board to access and assess drug pricing information, to the extent practicable, by accessing and assessing information from other states, by assessing spending for the drug in Wisconsin, and by accessing other available pricing information.
Under the bill, the board must conduct drug cost affordability reviews. The first step in the reviews is for the board to identify prescription drugs whose launch wholesale acquisition cost exceeds specified thresholds, prescription drugs whose increase in wholesale acquisition cost exceeds specified thresholds, and other prescription drugs that may create affordability challenges for the health care system in Wisconsin. For each identified prescription drug, the board must determine whether to conduct an affordability review by seeking stakeholder input and by considering the average patient cost share for the drug. During an affordability review, the board must determine whether use of the prescription drug that is fully consistent with the labeling approved by the federal Food and Drug Administration or standard medical practice has led or will lead to an affordability challenge for the health care system in Wisconsin. In making this determination, the bill requires the board to consider a variety of factors, which include the following:
1. The drug’s wholesale acquisition cost.
2. The average monetary price concession, discount, or rebate the manufacturer provides, or is expected to provide, for the drug to health plans.
3. The total amount of price concessions, discounts, and rebates the manufacturer provides to each pharmacy benefit manager for the drug.
4. The price at which therapeutic alternatives have been sold and the average monetary concession, discount, or rebate the manufacturer provides, or is expected to provide, to health plan payors and pharmacy benefit managers for therapeutic alternatives.
5. The costs to health plans based on patient access consistent with federal labeled indications and recognized standard medical practice.
6. The impact on patient access resulting from the drug’s cost relative to insurance benefit design.
7. The current or expected dollar value of drug-specific patient access programs that are supported by the manufacturer.
8. The relative financial impacts to health, medical, or social services costs that can be quantified and compared to baseline effects of existing therapeutic alternatives.
9. The average patient copay or other cost sharing for the drug.
If the board determines that a prescription drug will lead to an affordability challenge, the bill directs the board to establish an upper payment limit for that drug that applies to all purchases and payor reimbursements of the drug dispensed or administered to individuals in this state. In establishing the upper payment limit, the board must consider the cost of administering the drug, the cost of delivering it to consumers, and other relevant administrative costs. For certain drugs, the board must solicit information from the manufacturer regarding the price increase and, if the board determines that the price increase is not a result of the need for increased manufacturing capacity or other effort to improve patient access during a public health emergency, the board must establish an upper payment limit equal to the drug’s cost prior to the price increase.
Cost-sharing cap on insulin
The bill prohibits each health insurance policy and governmental self-insured health plan that covers insulin and imposes cost sharing on prescription drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a one-month supply. Current law requires each health insurance policy that provides coverage of expenses incurred for treatment of diabetes to provide coverage for specified expenses and items, including insulin. The required coverage under current law for certain diabetes treatments other than insulin infusion pumps is subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy as other covered expenses. The bill’s cost-sharing limitation on insulin supersedes the specification that the exclusions, limitations, deductibles, and coinsurance are the same as for other coverage.
Insulin safety net programs
The bill requires insulin manufacturers to establish a program under which qualifying residents of this state who are in urgent need of insulin and are uninsured or have limited insurance coverage can be dispensed insulin at a pharmacy. Under the program, if a qualifying individual in urgent need of insulin provides a pharmacy with a form attesting that the individual meets the program’s eligibility requirements, specified proof of residency, and a valid insulin prescription, the pharmacy must dispense a 30-day supply of insulin to the individual and may charge the individual a copayment of no more than $35. The pharmacy may submit an electronic payment claim for the insulin’s acquisition cost to the manufacturer or agree to receive a replacement of the same insulin in the amount dispensed.
The bill also requires that each insulin manufacturer establish a patient assistance program to make insulin available to any qualifying resident of this state who, among other requirements, is uninsured or has limited insurance coverage and whose family income does not exceed 400 percent of the federal poverty line. Under the bill, an individual must apply to participate in a manufacturer’s program. If the manufacturer determines that the individual meets the program’s eligibility requirements, the manufacturer must issue the individual a statement of eligibility, which is valid for 12 months and may be renewed. Under the bill, if an individual with a statement of eligibility and valid insulin prescription requests insulin from a pharmacy, the pharmacy must submit an order to the manufacturer, who must then provide a 90-day supply of insulin at no charge to the individual or pharmacy. The pharmacy may charge the individual a copayment of no more than $50. Under the bill, a manufacturer is not required to issue a statement of eligibility if the individual has prescription drug coverage through an individual or group health plan and the manufacturer determines that the individual’s insulin needs are better addressed through the manufacturer’s copayment assistance program. In such case, the manufacturer must provide the individual with the necessary drug coupons, and the individual may not be required to pay more than a $50 copayment for a 90-day supply of insulin.
Under the bill, if the manufacturer determines that an individual is not eligible for the patient assistance program, the individual may file an appeal with OCI. The bill directs OCI to establish procedures for deciding appeals. Under the bill, OCI must issue a decision within 10 days, and that decision is final.
The bill requires that insulin manufacturers annually report to OCI certain information, including the number of individuals served and the cost of insulin dispensed under the programs, and that OCI annually report to the governor and the legislature on the programs. The bill also directs OCI to conduct public outreach and develop an information sheet about the programs, conduct satisfaction surveys of individuals and pharmacies that participate in the programs, and report to the governor and the legislature on the surveys by July 1, 2026. Additionally, the bill requires that OCI develop a training program for health care navigators to assist individuals in accessing appropriate long-term insulin options and maintain a list of trained navigators.
The bill provides that a manufacturer that violates the bill’s provisions may be required to forfeit not more than $200,000 per month of violation, which increases to $400,000 per month if the manufacturer continues to be in violation after six months and to $600,000 per month if the manufacturer continues to be in violation after one year. The bill’s requirements do not apply to manufacturers with annual insulin sales revenue in this state of no more than $2,000,000 or to insulin that costs less than a specified dollar amount.
Application of manufacturer discounts
Health insurance policies and plans often apply deductibles and out-of-pocket maximum amounts to the benefits covered by the policy or plan. A deductible is an amount that an enrollee in a policy or plan must pay out of pocket before attaining the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit specified by a policy or plan on the amount that an enrollee pays, and once that limit is reached, the policy or plan covers the benefit entirely. The bill requires health insurance policies that offer prescription drug benefits and self-insured health plans to apply the amount of any discounts that a manufacturer of a brand name drug provides to reduce the amount of cost sharing that is charged to an enrollee for those brand name drugs to the enrollee’s deductible and out-of-pocket maximum amount. That requirement applies for brand name drugs that have no generic equivalent and for brand name drugs that have a generic equivalent but that the enrollee has prior authorization or physician approval to obtain.
Reimbursement to federal drug pricing program participants
The bill prohibits any person from reimbursing certain entities that participate in the federal drug pricing program, known as the 340B program, for a drug subject to an agreement under the program at a rate lower than that paid for the same drug to pharmacies that have a similar prescription volume. The bill also prohibits a person from imposing any fee, charge back, or other adjustment on the basis of the entity’s participation in the 340B program. The entities covered by the prohibitions under the bill are federally qualified health centers, critical access hospitals, and grantees under the federal Ryan White HIV/AIDS program, as well as these entities’ pharmacies and any pharmacy with which any of the entities have contracted to dispense drugs through the 340B program. The bill allows the commissioner to promulgate administrative rules to establish a minimum reimbursement rate for entities that participate in the 340B program.
Value-based diabetes medication pilot project
The bill directs OCI to develop a pilot project under which a pharmacy benefit manager and a pharmaceutical manufacturer are directed to create a value-based, sole-source arrangement to reduce the costs of prescription diabetes medication. The bill allows OCI to promulgate administrative rules to implement the pilot project.
Pharmacy services administrative organizations
The bill requires that a pharmacy services administrative organization (PSAO) be licensed by OCI. Under the bill, a PSAO is an entity operating in Wisconsin that does all of the following:
1. Contracts with an independent pharmacy to conduct business on the pharmacy’s behalf with a third-party payer.
