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AB50,1412,632. Increased by at least 200 percent during the preceding 12-month period, as
4determined by the difference between the resulting wholesale acquisition cost and
5the average of the wholesale acquisition cost reported over the preceding 12
6months.
AB50,1412,97(e) Other prescription drug products, including drugs to address public health
8emergencies, that may create affordability challenges for the health care system
9and patients in this state.
AB50,1412,1410(2) Affordability review. (a) After identifying prescription drug products
11under sub. (1), the board shall determine whether to conduct an affordability
12review for each identified prescription drug product by seeking stakeholder input
13about the prescription drug product and considering the average patient cost share
14of the prescription drug product.
AB50,1412,2015(b) The information used to conduct an affordability review under par. (a) may
16include any document and research related to the manufacturers selection of the
17introductory price or price increase of the prescription drug product, including life
18cycle management, net average price in this state, market competition and context,
19projected revenue, and the estimated value or cost-effectiveness of the prescription
20drug product.
AB50,1412,2321(c) The failure of a manufacturer to provide the board with information for an
22affordability review under par. (b) does not affect the authority of the board to
23conduct the review.
AB50,1413,8
1(3) Affordability challenge. When conducting an affordability review of a
2prescription drug product under sub. (2), the board shall determine whether use of
3the prescription drug product that is fully consistent with the labeling approved by
4the federal food and drug administration or standard medical practice has led or
5will lead to an affordability challenge for the health care system in this state,
6including high out-of-pocket costs for patients. To the extent practicable, in
7determining whether a prescription drug product has led or will lead to an
8affordability challenge, the board shall consider all of the following factors:
AB50,1413,109(a) The wholesale acquisition cost for the prescription drug product sold in
10this state.
AB50,1413,1411(b) The average monetary price concession, discount, or rebate the
12manufacturer provides, or is expected to provide, to health plans in this state as
13reported by manufacturers and health plans, expressed as a percentage of the
14wholesale acquisition cost for the prescription drug product under review.
AB50,1413,1815(c) The total amount of the price concessions, discounts, and rebates the
16manufacturer provides to each pharmacy benefit manager for the prescription drug
17product under review, as reported by the manufacturer and pharmacy benefit
18manager and expressed as a percentage of the wholesale acquisition cost.
AB50,1413,2019(d) The price at which therapeutic alternatives to the prescription drug
20product have been sold in this state.
AB50,1413,2321(e) The average monetary concession, discount, or rebate the manufacturer
22provides or is expected to provide to health plan payors and pharmacy benefit
23managers in this state for therapeutic alternatives to the prescription drug product.
AB50,1414,3
1(f) The costs to health plans based on patient access consistent with labeled
2indications by the federal food and drug administration and recognized standard
3medical practice.
AB50,1414,54(g) The impact on patient access resulting from the cost of the prescription
5drug product relative to insurance benefit design.
AB50,1414,76(h) The current or expected dollar value of drug-specific patient access
7programs that are supported by the manufacturer.
AB50,1414,108(i) The relative financial impacts to health, medical, or social services costs
9that can be quantified and compared to baseline effects of existing therapeutic
10alternatives to the prescription drug product.
AB50,1414,1211(j) The average patient copay or other cost sharing for the prescription drug
12product in this state.
AB50,1414,1313(k) Any information a manufacturer chooses to provide.
AB50,1414,1414(L) Any other factors as determined by the board by rule.
AB50,1414,1815(4) Upper payment limit. (a) If the board determines under sub. (3) that use
16of a prescription drug product has led or will lead to an affordability challenge, the
17board shall establish an upper payment limit for the prescription drug product after
18considering all of the following:
AB50,1414,19191. The cost of administering the drug.
AB50,1414,20202. The cost of delivering the drug to consumers.
AB50,1414,21213. Other relevant administrative costs related to the drug.
AB50,1415,422(b) For a prescription drug product identified in sub. (1) (b) or (d) 2., the board
23shall solicit information from the manufacturer regarding the price increase. To

1the extent that the price increase is not a result of the need for increased
2manufacturing capacity or other effort to improve patient access during a public
3health emergency, the board shall establish an upper payment limit under par. (a)
4that is equal to the cost to consumers prior to the price increase.
AB50,1415,85(c) 1. The upper payment limit established under this subsection shall apply
6to all purchases and payor reimbursements of the prescription drug product
7dispensed or administered to individuals in this state in person, by mail, or by other
8means.
AB50,1415,1992. Notwithstanding subd. 1., while state-sponsored and state-regulated
10health plans and health programs shall limit drug reimbursements and drug
11payment to no more than the upper payment limit established under this
12subsection, a plan subject to the Employee Retirement Income Security Act of 1974
13or Part D of Medicare under 42 USC 1395w-101 et seq. may choose to reimburse
14more than the upper payment limit. A provider who dispenses and administers a
15prescription drug product in this state to an individual in this state may not bill a
16payor more than the upper payment limit to the patient regardless of whether a
17plan subject to the Employee Retirement Income Security Act of 1974 or Part D of
18Medicare under 42 USC 1395w-101 et seq. chooses to reimburse the provider above
19the upper payment limit.
AB50,1415,2120(5) Public inspection. Information submitted to the board under this
21section shall be open to public inspection only as provided under ss. 19.31 to 19.39.
AB50,1416,222(6) No prohibition on marketing. Nothing in this section may be construed
23to prevent a manufacturer from marketing a prescription drug product approved by

1the federal food and drug administration while the prescription drug product is
2under review by the board.
AB50,1416,73(7) Appeals. A person aggrieved by a decision of the board may request an
4appeal of the decision no later than 30 days after the board makes the
5determination. The board shall hear the appeal and make a final decision no later
6than 60 days after the appeal is requested. A person aggrieved by a final decision of
7the board may petition for judicial review in a court of competent jurisdiction.
AB50,28948Section 2894. 601.83 (1) (a) of the statutes is amended to read:
AB50,1416,219601.83 (1) (a) The commissioner shall administer a state-based reinsurance
10program known as the healthcare stability plan in accordance with the specific
11terms and conditions approved by the federal department of health and human
12services dated July 29, 2018. Before December 31, 2023, the commissioner may not
13request from the federal department of health and human services a modification,
14suspension, withdrawal, or termination of the waiver under 42 USC 18052 under
15which the healthcare stability plan under this subchapter operates unless
16legislation has been enacted specifically directing the modification, suspension,
17withdrawal, or termination. Before December 31, 2023, the commissioner may
18request renewal, without substantive change, of the waiver under 42 USC 18052
19under which the health care stability plan operates in accordance with s. 20.940 (4)
20unless legislation has been enacted that is contrary to such a renewal request. The
21commissioner shall comply with applicable timing in and requirements of s. 20.940.
AB50,289522Section 2895. 601.83 (1) (h) of the statutes is renumbered 601.83 (1) (h)
23(intro.) and amended to read:
AB50,1417,424601.83 (1) (h) (intro.) In 2019 and in each subsequent year, the The

1commissioner may expend no more than $200,000,000 the following amounts from
2all revenue sources for the healthcare stability plan under this section, unless the
3joint committee on finance under s. 13.10 governor has increased this amount upon
4request by the commissioner.:
AB50,1417,85(he) The commissioner shall ensure that sufficient funds are available for the
6healthcare stability plan under this section to operate as described in the approval
7of the federal department of health and human services dated July 29, 2018, and in
8any waiver extension approvals.
AB50,28969Section 2896. 601.83 (1) (h) 1. to 3. of the statutes are created to read:
AB50,1417,1010601.83 (1) (h) 1. In 2025, $230,000,000.
AB50,1417,11112. In 2026, $250,000,000.
AB50,1417,20123. In 2027 and in each year thereafter, the maximum expenditure amount for
13the previous year, adjusted to reflect the percentage increase, if any, in the
14consumer price index for all urban consumers, U.S. city average, for the medical
15care group, as determined by the U.S. department of labor, for the 12-month period
16ending on December 31 of the year before the year in which the amount is
17determined. The commissioner shall determine the annual adjustment amount for
18a particular year in January of the previous year. The commissioner shall publish
19the new maximum expenditure amount under this subdivision each year in the
20Wisconsin Administrative Register.
AB50,289721Section 2897. 601.83 (1) (hm) of the statutes is repealed.
AB50,289822Section 2898. 609.04 of the statutes is created to read:
AB50,1417,2423609.04 Preventing surprise medical bills; emergency medical
24services. (1) Definitions. In this section:
AB50,1418,1
1(a) Emergency medical condition means all of the following:
AB50,1418,521. A medical condition, including a mental health condition or substance use
3disorder condition, manifesting itself by acute symptoms of sufficient severity,
4including severe pain, such that the absence of immediate medical attention could
5reasonably be expected to result in any of the following:
AB50,1418,76a. Placing the health of the individual or, with respect to a pregnant woman,
7the health of the woman or her unborn child in serious jeopardy.
AB50,1418,88b. Serious impairment of bodily function.
AB50,1418,99c. Serious dysfunction of any bodily organ or part.
AB50,1418,13102. With respect to a pregnant woman who is having contractions, a medical
11condition for which there is inadequate time to safely transfer the pregnant woman
12to another hospital before delivery or for which the transfer may pose a threat to the
13health or safety of the pregnant woman or the unborn child.
AB50,1418,1614(b) Emergency medical services, with respect to an emergency medical
15condition, has the meaning given for emergency services in 42 USC 300gg-111 (a)
16(3) (C).
AB50,1418,1817(c) Independent freestanding emergency department has the meaning given
18in 42 USC 300gg-111 (a) (3) (D).
AB50,1418,2019(d) Out-of-network rate has the meaning given by the commissioner by rule
20or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).
AB50,1419,221(e) Preferred provider plan, notwithstanding s. 609.01 (4), includes only any
22preferred provider plan, as defined in s. 609.01 (4), that has a network of

1participating providers and imposes on enrollees different requirements for using
2providers that are not participating providers.
AB50,1419,43(f) Recognized amount has the meaning given by the commissioner by rule
4or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).
AB50,1419,85(g) Self-insured governmental plan means a self-insured health plan of the
6state or a county, city, village, town, or school district that has a network of
7participating providers and imposes on enrollees in the self-insured health plan
8different requirements for using providers that are not participating providers.
AB50,1419,119(h) Terminated means the expiration or nonrenewal of a contract.
10Terminated does not include a termination of a contract for failure to meet
11applicable quality standards or for fraud.
AB50,1419,1612(2) Emergency medical services. A defined network plan, preferred
13provider plan, or self-insured governmental plan that covers any benefits or
14services provided in an emergency department of a hospital or emergency medical
15services provided in an independent freestanding emergency department shall
16cover emergency medical services in accordance with all of the following:
AB50,1419,1717(a) The plan may not require a prior authorization determination.
AB50,1419,2018(b) The plan may not deny coverage on the basis of whether or not the health
19care provider providing the services is a participating provider or participating
20facility.
AB50,1419,2321(c) If the emergency medical services are provided to an enrollee by a provider
22or in a facility that is not a participating provider or participating facility, the plan
23complies with all of the following:
AB50,1420,4
11. The emergency medical services are covered without imposing on an
2enrollee a requirement for prior authorization or any coverage limitation that is
3more restrictive than requirements or limitations that apply to emergency medical
4services provided by participating providers or in participating facilities.
AB50,1420,852. Any cost-sharing requirement imposed on an enrollee for the emergency
6medical services is no greater than the requirements that would apply if the
7emergency medical services were provided by a participating provider or in a
8participating facility.
AB50,1420,1393. Any cost-sharing amount imposed on an enrollee for the emergency medical
10services is calculated as if the total amount that would have been charged for the
11emergency medical services if provided by a participating provider or in a
12participating facility is equal to the recognized amount for such services, plan or
13coverage, and year.
AB50,1420,14144. The plan does all of the following:
AB50,1420,1715a. No later than 30 days after the participating provider or participating
16facility transmits to the plan the bill for emergency medical services, sends to the
17provider or facility an initial payment or a notice of denial of payment.
AB50,1420,2018b. Pays to the participating provider or participating facility a total amount
19that, incorporating any initial payment under subd. 4. a., is equal to the amount by
20which the out-of-network rate exceeds the cost-sharing amount.
AB50,1421,2215. The plan counts any cost-sharing payment made by the enrollee for the
22emergency medical services toward any in-network deductible or out-of-pocket
23maximum applied by the plan in the same manner as if the cost-sharing payment

1was made for emergency medical services provided by a participating provider or in
2a participating facility.
AB50,1421,83(3) Nonparticipating provider in participating facility. For items or
4services other than emergency medical services that are provided to an enrollee of
5a defined network plan, preferred provider plan, or self-insured governmental plan
6by a provider who is not a participating provider but who is providing services at a
7participating facility, the plan shall provide coverage for the item or service in
8accordance with all of the following:
AB50,1421,119(a) The plan may not impose on an enrollee a cost-sharing requirement for the
10item or service that is greater than the cost-sharing requirement that would have
11been imposed if the item or service was provided by a participating provider.
AB50,1421,1512(b) Any cost-sharing amount imposed on an enrollee for the item or service is
13calculated as if the total amount that would have been charged for the item or
14service if provided by a participating provider is equal to the recognized amount for
15such item or service, plan or coverage, and year.
AB50,1421,1716(c) No later than 30 days after the provider transmits the bill for services, the
17plan shall send to the provider an initial payment or a notice of denial of payment.
AB50,1421,2118(d) The plan shall make a total payment directly to the provider who provided
19the item or service to the enrollee that, added to any initial payment described
20under par. (c), is equal to the amount by which the out-of-network rate for the item
21or service exceeds the cost-sharing amount.
AB50,1422,222(e) The plan counts any cost-sharing payment made by the enrollee for the
23item or service toward any in-network deductible or out-of-pocket maximum

1applied by the plan in the same manner as if the cost-sharing payment was made
2for the item or service when provided by a participating provider.
AB50,1422,83(4) Charging for services by nonparticipating provider; notice and
4consent. (a) Except as provided in par. (c), a provider of an item or service who is
5entitled to payment under sub. (3) may not bill or hold liable an enrollee for any
6amount for the item or service that is more than the cost-sharing amount
7calculated under sub. (3) (b) for the item or service unless the nonparticipating
8provider provides notice and obtains consent in accordance with all of the following:
AB50,1422,1191. The notice states that the provider is not a participating provider in the
10enrollees defined network plan, preferred provider plan, or self-insured
11governmental plan.
AB50,1422,15122. The notice provides a good faith estimate of the amount that the
13nonparticipating provider may charge the enrollee for the item or service involved,
14including notification that the estimate does not constitute a contract with respect
15to the charges estimated for the item or service.
AB50,1422,18163. The notice includes a list of the participating providers at the participating
17facility who would be able to provide the item or service and notification that the
18enrollee may be referred to one of those participating providers.
AB50,1422,21194. The notice includes information about whether or not prior authorization or
20other care management limitations may be required before receiving an item or
21service at the participating facility.
AB50,1422,23225. The notice clearly states that consent is optional and that the patient may
23elect to seek care from an in-network provider.
AB50,1423,1
16. The notice is worded in plain language.
AB50,1423,327. The notice is available in languages other than English. The commissioner
3shall identify languages for which the notice should be available.
AB50,1423,848. The enrollee provides consent to the nonparticipating provider to be treated
5by the nonparticipating provider, and the consent acknowledges that the enrollee
6has been informed that the charge paid by the enrollee may not meet a limitation
7that the enrollees defined network plan, preferred provider plan, or self-insured
8governmental plan places on cost sharing, such as an in-network deductible.
AB50,1423,1099. A signed copy of the consent described under subd. 8. is provided to the
10enrollee.
AB50,1423,1211(b) To be considered adequate, the notice and consent under par. (a) shall meet
12one of the following requirements, as applicable:
AB50,1423,16131. If the enrollee makes an appointment for the item or service at least 72
14hours before the day on which the item or service is to be provided, any notice under
15par. (a) shall be provided to the enrollee at least 72 hours before the day of the
16appointment at which the item or service is to be provided.
AB50,1423,19172. If the enrollee makes an appointment for the item or service less than 72
18hours before the day on which the item or service is to be provided, any notice under
19par. (a) shall be provided to the enrollee on the day that the appointment is made.
AB50,1424,320(c) A provider of an item or service who is entitled to payment under sub. (3)
21may not bill or hold liable an enrollee for any amount for an ancillary item or
22service that is more than the cost-sharing amount calculated under sub. (3) (b) for
23the item or service, whether or not provided by a physician or non-physician

1practitioner, unless the commissioner specifies by rule that the provider may bill or
2hold the enrollee liable for the ancillary item or service, if the item or service is any
3of the following:
AB50,1424,441. Related to an emergency medical service.
AB50,1424,552. Anesthesiology.
AB50,1424,663. Pathology.
AB50,1424,774. Radiology.
AB50,1424,885. Neonatology.
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