Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,124,4 (c) No later than 30 days after the provider transmits the bill for services, the plan shall send to the provider an initial payment or a notice of denial of payment.

SB45-SSA2-SA4,124,8 (d) The plan shall make a total payment directly to the provider who provided the item or service to the enrollee that, added to any initial payment described under par. (c), is equal to the amount by which the out-of-network rate for the item or service exceeds the cost-sharing amount.

SB45-SSA2-SA4,124,12 (e) The plan counts any cost-sharing payment made by the enrollee for the item or service toward any in-network deductible or out-of-pocket maximum applied by the plan in the same manner as if the cost-sharing payment was made for the item or service when provided by a participating provider.

SB45-SSA2-SA4,124,18 (4) Charging for services by nonparticipating provider; notice and consent. (a) Except as provided in par. (c), a provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for the item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service unless the nonparticipating provider provides notice and obtains consent in accordance with all of the following:

SB45-SSA2-SA4,124,21 1. The notice states that the provider is not a participating provider in the enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan.

SB45-SSA2-SA4,125,2 2. The notice provides a good faith estimate of the amount that the nonparticipating provider may charge the enrollee for the item or service involved, including notification that the estimate does not constitute a contract with respect to the charges estimated for the item or service.

SB45-SSA2-SA4,125,5 3. The notice includes a list of the participating providers at the participating facility who would be able to provide the item or service and notification that the enrollee may be referred to one of those participating providers.

SB45-SSA2-SA4,125,8 4. The notice includes information about whether or not prior authorization or other care management limitations may be required before receiving an item or service at the participating facility.

SB45-SSA2-SA4,125,10 5. The notice clearly states that consent is optional and that the patient may elect to seek care from an in-network provider.

SB45-SSA2-SA4,125,11 6. The notice is worded in plain language.

SB45-SSA2-SA4,125,13 7. The notice is available in languages other than English. The commissioner shall identify languages for which the notice should be available.

SB45-SSA2-SA4,125,18 8. The enrollee provides consent to the nonparticipating provider to be treated by the nonparticipating provider, and the consent acknowledges that the enrollee has been informed that the charge paid by the enrollee may not meet a limitation that the enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan places on cost sharing, such as an in-network deductible.

SB45-SSA2-SA4,125,20 9. A signed copy of the consent described under subd. 8. is provided to the enrollee.

SB45-SSA2-SA4,125,22 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

SB45-SSA2-SA4,126,3 1. If the enrollee makes an appointment for the item or service at least 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee at least 72 hours before the day of the appointment at which the item or service is to be provided.

SB45-SSA2-SA4,126,6 2. If the enrollee makes an appointment for the item or service less than 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee on the day that the appointment is made.

SB45-SSA2-SA4,126,13 (c) A provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for an ancillary item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service, whether or not provided by a physician or non-physician practitioner, unless the commissioner specifies by rule that the provider may bill or hold the enrollee liable for the ancillary item or service, if the item or service is any of the following:

SB45-SSA2-SA4,126,14 1. Related to an emergency medical service.

SB45-SSA2-SA4,126,15 2. Anesthesiology.

SB45-SSA2-SA4,126,16 3. Pathology.

SB45-SSA2-SA4,126,17 4. Radiology.

SB45-SSA2-SA4,126,18 5. Neonatology.

SB45-SSA2-SA4,126,20 6. An item or service provided by an assistant surgeon, hospitalist, or intensivist.

SB45-SSA2-SA4,126,21 7. A diagnostic service, including a radiology or laboratory service.

SB45-SSA2-SA4,126,23 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

SB45-SSA2-SA4,127,3 9. An item or service provided by a nonparticipating provider when there is no participating provider who can furnish the item or service at the participating facility.

SB45-SSA2-SA4,127,6 (d) Any notice and consent provided under par. (a) may not extend to items or services furnished as a result of unforeseen, urgent medical needs that arise at the time the item or service is provided.

SB45-SSA2-SA4,127,8 (e) Any consent provided under par. (a) shall be retained by the provider for no less than 7 years.

SB45-SSA2-SA4,127,18 (5) Notice by provider or facility. Beginning no later than January 1, 2026, a health care provider or health care facility shall make available, including posting on a website, to enrollees in defined network plans, preferred provider plans, and self-insured governmental plans notice of the requirements on a provider or facility under sub. (4), of any other applicable state law requirements on the provider or facility with respect to charging an enrollee for an item or service if the provider or facility does not have a contractual relationship with the plan, and of information on contacting appropriate state or federal agencies in the event the enrollee believes the provider or facility violates any of the requirements under this section or other applicable law.

SB45-SSA2-SA4,128,12 (6) Negotiation; dispute resolution. A provider or facility that is entitled to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may initiate, within 30 days of receiving the initial payment or notice of denial, open negotiations with the defined network plan, preferred provider plan, or self-insured governmental plan to determine a payment amount for an emergency medical service or other item or service for a period that terminates 30 days after initiating open negotiations. If the open negotiation period under this subsection terminates without determination of a payment amount, the provider, facility, defined network plan, preferred provider plan, or self-insured governmental plan may initiate, within the 4 days beginning on the day after the open negotiation period ends, the independent dispute resolution process as specified by the commissioner. If the independent dispute resolution decision-maker determines the payment amount, the party to the independent dispute resolution process whose amount was not selected shall pay the fees for the independent dispute resolution. If the parties to the independent dispute resolution reach a settlement on the payment amount, the parties to the independent dispute resolution shall equally divide the payment for the fees for the independent dispute resolution.

SB45-SSA2-SA4,128,13 (7) Continuity of care. (a) In this subsection:

SB45-SSA2-SA4,128,14 1. “Continuing care patient” means an individual who is any of the following:

SB45-SSA2-SA4,128,16 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

SB45-SSA2-SA4,128,18 b. Undergoing a course of institutional or inpatient care from a provider or facility.

SB45-SSA2-SA4,128,20 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

SB45-SSA2-SA4,128,22 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

SB45-SSA2-SA4,129,2 e. Terminally ill and receiving treatment for the illness from a provider or facility.

SB45-SSA2-SA4,129,3 2. “Serious and complex condition” means any of the following:

SB45-SSA2-SA4,129,6 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.

SB45-SSA2-SA4,129,9 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.

SB45-SSA2-SA4,129,17 (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:

SB45-SSA2-SA4,129,20 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.

SB45-SSA2-SA4,129,22 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

SB45-SSA2-SA4,130,6 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.

SB45-SSA2-SA4,130,9 (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.

SB45-SSA2-SA4,130,17 (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 bill or hold liable an enrollee 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 Surprises Act, 42 USC 300gg-111, et seq.

SB45-SSA2-SA4,199 Section 199. 609.20 (3) of the statutes is created to read:

SB45-SSA2-SA4,131,2 609.20 (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).

SB45-SSA2-SA4,200 Section 200. 609.24 (5) of the statutes is created to read:

SB45-SSA2-SA4,131,7 609.24 (5) Duration of benefits. If an enrollee is a continuing care patient, as defined in s. 609.04 (7) (a), and if any of the situations described under s. 609.04 (7) (b) (intro.) applies, all of the following apply to the enrollee’s defined network plan:

SB45-SSA2-SA4,131,10 (a) Subsection (1) (c) shall apply to any of the participating providers providing the enrollee’s course of treatment under s. 609.04 (7), including the enrollee’s primary care physician.

SB45-SSA2-SA4,131,13 (b) Subsection (1) (c) shall apply to lengthen the period in which benefits are provided under s. 609.04 (7) (b) 3. but may not be applied to shorten the period in which benefits are provided under s. 609.04 (7) (b) 3.

SB45-SSA2-SA4,131,15 (c) Subsection (1) (d) may not be applied in a manner that limits the enrollee’s rights under s. 609.04 (7) (b) 3.

SB45-SSA2-SA4,131,18 (d) No plan may contract or arrange with a participating provider to provide notice of the termination of the participating provider’s participation, pursuant to sub. (4).

SB45-SSA2-SA4,201 Section 201. 609.40 of the statutes is created to read:

SB45-SSA2-SA4,131,21 609.40 Special enrollment period for pregnancy. Preferred provider plans and defined network plans are subject to s. 632.7498.

SB45-SSA2-SA4,202 Section 202. 609.712 of the statutes is created to read:

SB45-SSA2-SA4,132,2 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

SB45-SSA2-SA4,203 Section 203. 609.713 of the statutes is created to read:

SB45-SSA2-SA4,132,6 609.713 Qualified treatment trainee coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (7).

SB45-SSA2-SA4,204 Section 204. 609.714 of the statutes is created to read:

SB45-SSA2-SA4,132,10 609.714 Substance abuse counselor coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (8).

SB45-SSA2-SA4,205 Section 205. 609.718 of the statutes is created to read:

SB45-SSA2-SA4,132,13 609.718 Dental therapist coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (4e).

SB45-SSA2-SA4,206 Section 206. 609.719 of the statutes is created to read:

SB45-SSA2-SA4,132,17 609.719 Coverage for telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

SB45-SSA2-SA4,207 Section 207. 609.74 of the statutes is created to read:

SB45-SSA2-SA4,132,20 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

SB45-SSA2-SA4,208 Section 208. 609.815 of the statutes is created to read:

SB45-SSA2-SA4,132,24 609.815 Exemption from prior authorization requirements. Limited service health organizations, preferred provider plans, and defined network plans are subject to any rules promulgated by the commissioner under s. 632.848.

SB45-SSA2-SA4,209 Section 209. 609.823 of the statutes is created to read:

SB45-SSA2-SA4,133,4 609.823 Coverage without prior authorization for inpatient mental health services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.891.

SB45-SSA2-SA4,210 Section 210. 609.825 of the statutes is created to read:

SB45-SSA2-SA4,133,7 609.825 Coverage of emergency ambulance services. (1) In this section:

SB45-SSA2-SA4,133,8 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

SB45-SSA2-SA4,133,12 (b) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

SB45-SSA2-SA4,133,17 (2) A defined network plan, preferred provider plan, or self-insured governmental plan that provides coverage of emergency medical services shall cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is not lower than the greatest rate that is any of the following:

SB45-SSA2-SA4,133,19 (a) A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.

SB45-SSA2-SA4,134,2 (b) A rate that is 400 percent of the current published rate for the provided emergency ambulance services established by the federal centers for medicare and medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 et seq., in the same geographic area or a rate that is equivalent to the rate billed by the ambulance service provider for emergency ambulance services provided, whichever is less.

SB45-SSA2-SA4,134,5 (c) The contracted rate at which the defined network plan, preferred provider plan, or self-insured governmental plan would reimburse a participating ambulance service provider for the same emergency ambulance services.

SB45-SSA2-SA4,134,11 (3) No defined network plan, preferred provider plan, or self-insured governmental plan may impose a cost-sharing amount on an enrollee for emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is greater than the requirements that would apply if the emergency ambulance services were provided by a participating ambulance service provider.

SB45-SSA2-SA4,134,15 (4) No ambulance service provider that receives reimbursement under this section may bill an enrollee for any additional amount for emergency ambulance services except for any copayment, coinsurance, deductible, or other cost-sharing responsibilities required to be paid by the enrollee.

SB45-SSA2-SA4,134,17 (5) For purposes of this section, “emergency ambulance services” does not include air ambulance services.

SB45-SSA2-SA4,211 Section 211. 609.83 of the statutes is amended to read:

SB45-SSA2-SA4,134,22 609.83 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).

SB45-SSA2-SA4,212 Section 212. 609.847 of the statutes is created to read:

SB45-SSA2-SA4,135,2 609.847 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.

SB45-SSA2-SA4,213 Section 213. 625.12 (1) (a) of the statutes is amended to read:

SB45-SSA2-SA4,135,5 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.