AB50,1424,552. Anesthesiology. AB50,1424,663. Pathology. AB50,1424,774. Radiology. AB50,1424,885. Neonatology. AB50,1424,1096. An item or service provided by an assistant surgeon, hospitalist, or 10intensivist. AB50,1424,11117. A diagnostic service, including a radiology or laboratory service. AB50,1424,13128. An item or service provided by a specialty practitioner that the 13commissioner specifies by rule. AB50,1424,16149. An item or service provided by a nonparticipating provider when there is no 15participating provider who can furnish the item or service at the participating 16facility. AB50,1424,1917(d) Any notice and consent provided under par. (a) may not extend to items or 18services furnished as a result of unforeseen, urgent medical needs that arise at the 19time the item or service is provided. AB50,1424,2120(e) Any consent provided under par. (a) shall be retained by the provider for no 21less than 7 years. AB50,1425,822(5) Notice by provider or facility. Beginning no later than January 1, 232026, a health care provider or health care facility shall make available, including
1posting on a website, to enrollees in defined network plans, preferred provider 2plans, and self-insured governmental plans notice of the requirements on a provider 3or facility under sub. (4), of any other applicable state law requirements on the 4provider or facility with respect to charging an enrollee for an item or service if the 5provider or facility does not have a contractual relationship with the plan, and of 6information on contacting appropriate state or federal agencies in the event the 7enrollee believes the provider or facility violates any of the requirements under this 8section or other applicable law. AB50,1426,29(6) Negotiation; dispute resolution. A provider or facility that is entitled 10to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may 11initiate, within 30 days of receiving the initial payment or notice of denial, open 12negotiations with the defined network plan, preferred provider plan, or self-insured 13governmental plan to determine a payment amount for an emergency medical 14service or other item or service for a period that terminates 30 days after initiating 15open negotiations. If the open negotiation period under this subsection terminates 16without determination of a payment amount, the provider, facility, defined network 17plan, preferred provider plan, or self-insured governmental plan may initiate, 18within the 4 days beginning on the day after the open negotiation period ends, the 19independent dispute resolution process as specified by the commissioner. If the 20independent dispute resolution decision-maker determines the payment amount, 21the party to the independent dispute resolution process whose amount was not 22selected shall pay the fees for the independent dispute resolution. If the parties to 23the independent dispute resolution reach a settlement on the payment amount, the
1parties to the independent dispute resolution shall equally divide the payment for 2the fees for the independent dispute resolution. AB50,1426,33(7) Continuity of care. (a) In this subsection: AB50,1426,441. “Continuing care patient” means an individual who is any of the following: AB50,1426,65a. Undergoing a course of treatment for a serious and complex condition from 6a provider or facility. AB50,1426,87b. Undergoing a course of institutional or inpatient care from a provider or 8facility. AB50,1426,109c. Scheduled to undergo nonelective surgery, including receipt of postoperative 10care, from a provider or facility. AB50,1426,1211d. Pregnant and undergoing a course of treatment for the pregnancy from a 12provider or facility. AB50,1426,1413e. Terminally ill and receiving treatment for the illness from a provider or 14facility. AB50,1426,15152. “Serious and complex condition” means any of the following: AB50,1426,1816a. In the case of an acute illness, a condition that is serious enough to require 17specialized medical treatment to avoid the reasonable possibility of death or 18permanent harm. AB50,1426,2119b. In the case of a chronic illness or condition, a condition that is life-20threatening, degenerative, potentially disabling, or congenital and requires 21specialized medical care over a prolonged period. AB50,1427,622(b) If an enrollee is a continuing care patient and is obtaining items or 23services from a participating provider or participating facility and the contract
1between the defined network plan, preferred provider plan, or self-insured 2governmental plan and the provider or facility is terminated because of a change in 3the terms of the participation of the provider or facility in the plan or the contract 4between the defined network plan, preferred provider plan, or self-insured 5governmental plan and the provider or facility is terminated, resulting in a loss of 6benefits provided under the plan, the plan shall do all of the following: AB50,1427,971. Notify each enrollee of the termination of the contract or benefits and of the 8right for the enrollee to elect to continue transitional care from the participating 9provider or participating facility under this subsection. AB50,1427,11102. Provide the enrollee an opportunity to notify the plan of the need for 11transitional care. AB50,1427,18123. Allow the enrollee to elect to continue to have the benefits provided under 13the plan under the same terms and conditions as would have applied to the item or 14service if the termination had not occurred for the course of treatment related to the 15enrollee’s status as a continuing care patient beginning on the date on which the 16notice under subd. 1. is provided and ending 90 days after the date on which the 17notice under subd. 1. is provided or the date on which the enrollee is no longer a 18continuing care patient, whichever is earlier. AB50,1427,2119(c) The provisions of s. 609.24 apply to a continuing care patient to the extent 20that s. 609.24 does not conflict with this subsection so as to limit the enrollee’s 21rights under this subsection. AB50,1428,622(8) Rule making. The commissioner may promulgate any rules necessary to 23implement this section, including specifying the independent dispute resolution
1process under sub. (6). The commissioner may promulgate rules to modify the list 2of those items and services for which a provider may not bill or hold liable an 3enrollee under sub. (4) (c). In promulgating rules under this subsection, the 4commissioner may consider any rules promulgated by the federal department of 5health and human services pursuant to the federal No Surprises Act, 42 USC 6300gg-111, et seq. AB50,28997Section 2899. 609.20 (3) of the statutes is created to read: AB50,1428,148609.20 (3) The commissioner may promulgate rules to establish minimum 9network time and distance standards and minimum network wait-time standards 10for defined network plans and preferred provider plans. In promulgating rules 11under this subsection, the commissioner shall consider standards adopted by the 12federal centers for medicare and medicaid services for qualified health plans, as 13defined in 42 USC 18021 (a), that are offered through the federal health insurance 14exchange established pursuant to 42 USC 18041 (c). AB50,290015Section 2900. 609.24 (5) of the statutes is created to read: AB50,1428,1916609.24 (5) Duration of benefits. If an enrollee is a continuing care patient, 17as defined in s. 609.04 (7) (a), and if any of the situations described under s. 609.04 18(7) (b) (intro.) applies, all of the following apply to the enrollee’s defined network 19plan: AB50,1428,2220(a) Subsection (1) (c) shall apply to any of the participating providers 21providing the enrollee’s course of treatment under s. 609.04 (7), including the 22enrollee’s primary care physician. AB50,1429,223(b) Subsection (1) (c) shall apply to lengthen the period in which benefits are
1provided under s. 609.04 (7) (b) 3. but may not be applied to shorten the period in 2which benefits are provided under s. 609.04 (7) (b) 3. AB50,1429,43(c) Subsection (1) (d) may not be applied in a manner that limits the enrollee’s 4rights under s. 609.04 (7) (b) 3. AB50,1429,75(d) No plan may contract or arrange with a participating provider to provide 6notice of the termination of the participating provider’s participation, pursuant to 7sub. (4). AB50,29018Section 2901. 609.40 of the statutes is created to read: AB50,1429,109609.40 Special enrollment period for pregnancy. Preferred provider 10plans and defined network plans are subject to s. 632.7498. AB50,290211Section 2902. 609.712 of the statutes is created to read: AB50,1429,1412609.712 Essential health benefits; preventive services. Defined 13network plans and preferred provider plans are subject to s. 632.895 (13m) and 14(14m). AB50,290315Section 2903. 609.713 of the statutes is created to read: AB50,1429,1816609.713 Qualified treatment trainee coverage. Limited service health 17organizations, preferred provider plans, and defined network plans are subject to s. 18632.87 (7). AB50,290419Section 2904. 609.714 of the statutes is created to read: AB50,1429,2220609.714 Substance abuse counselor coverage. Limited service health 21organizations, preferred provider plans, and defined network plans are subject to s. 22632.87 (8). AB50,290523Section 2905. 609.718 of the statutes is created to read: AB50,1430,2
1609.718 Dental therapist coverage. Limited service health organizations, 2preferred provider plans, and defined network plans are subject to s. 632.87 (4e). AB50,29063Section 2906. 609.719 of the statutes is created to read: AB50,1430,64609.719 Coverage for telehealth services. Limited service health 5organizations, preferred provider plans, and defined network plans are subject to s. 6632.871. AB50,29077Section 2907. 609.74 of the statutes is created to read: AB50,1430,98609.74 Coverage of infertility services. Defined network plans and 9preferred provider plans are subject to s. 632.895 (15m). AB50,290810Section 2908. 609.815 of the statutes is created to read: AB50,1430,1311609.815 Exemption from prior authorization requirements. Limited 12service health organizations, preferred provider plans, and defined network plans 13are subject to any rules promulgated by the commissioner under s. 632.848. AB50,290914Section 2909. 609.823 of the statutes is created to read: AB50,1430,1715609.823 Coverage without prior authorization for inpatient mental 16health services. Limited service health organizations, preferred provider plans, 17and defined network plans are subject to s. 632.891. AB50,291018Section 2910. 609.825 of the statutes is created to read: AB50,1430,2019609.825 Coverage of emergency ambulance services. (1) In this 20section: AB50,1430,2121(a) “Ambulance service provider” has the meaning given in s. 256.01 (3). AB50,1431,222(b) “Self-insured governmental plan” means a self-insured health plan of the 23state or a county, city, village, town, or school district that has a network of
1participating providers and imposes on enrollees in the self-insured health plan 2different requirements for using providers that are not participating providers. AB50,1431,73(2) A defined network plan, preferred provider plan, or self-insured 4governmental plan that provides coverage of emergency medical services shall 5cover emergency ambulance services provided by an ambulance service provider 6that is not a participating provider at a rate that is not lower than the greatest rate 7that is any of the following: AB50,1431,98(a) A rate that is set or approved by a local governmental entity in the 9jurisdiction in which the emergency ambulance services originated. AB50,1431,1510(b) A rate that is 400 percent of the current published rate for the provided 11emergency ambulance services established by the federal centers for medicare and 12medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 13et seq., in the same geographic area or a rate that is equivalent to the rate billed by 14the ambulance service provider for emergency ambulance services provided, 15whichever is less. AB50,1431,1816(c) The contracted rate at which the defined network plan, preferred provider 17plan, or self-insured governmental plan would reimburse a participating 18ambulance service provider for the same emergency ambulance services. AB50,1432,219(3) No defined network plan, preferred provider plan, or self-insured 20governmental plan may impose a cost-sharing amount on an enrollee for emergency 21ambulance services provided by an ambulance service provider that is not a 22participating provider at a rate that is greater than the requirements that would
1apply if the emergency ambulance services were provided by a participating 2ambulance service provider. AB50,1432,63(4) No ambulance service provider that receives reimbursement under this 4section may bill an enrollee for any additional amount for emergency ambulance 5services except for any copayment, coinsurance, deductible, or other cost-sharing 6responsibilities required to be paid by the enrollee. AB50,1432,87(5) For purposes of this section, “emergency ambulance services” does not 8include air ambulance services. AB50,29119Section 2911. 609.83 of the statutes is amended to read: AB50,1432,1310609.83 Coverage of drugs and devices; application of payments. 11Limited service health organizations, preferred provider plans, and defined 12network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), 13(16t), and (16v). AB50,291214Section 2912. 609.847 of the statutes is created to read: AB50,1432,1715609.847 Preexisting condition discrimination and certain benefit 16limits prohibited. Limited service health organizations, preferred provider 17plans, and defined network plans are subject to s. 632.728. AB50,291318Section 2913. 611.11 (4) (a) of the statutes is amended to read: AB50,1432,2019611.11 (4) (a) In this subsection, “municipality” has the meaning given in s. 20345.05 (1) (c), but also includes any transit authority created under s. 66.1039. AB50,291421Section 2914. 625.12 (1) (a) of the statutes is amended to read: AB50,1432,2322625.12 (1) (a) Past and prospective loss and expense experience within and 23outside of this state, except as provided in s. 632.728. AB50,291524Section 2915. 625.12 (1) (e) of the statutes is amended to read: AB50,1433,2
1625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, 2including the judgment of technical personnel. AB50,29163Section 2916. 625.12 (2) of the statutes is amended to read: AB50,1433,124625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, 5risks may be classified in any reasonable way for the establishment of rates and 6minimum premiums, except that no classifications may be based on race, color, 7creed or national origin, and classifications in automobile insurance may not be 8based on physical condition or developmental disability as defined in s. 51.01 (5). 9Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified 10for individual risks in accordance with rating plans or schedules that establish 11reasonable standards for measuring probable variations in hazards, expenses, or 12both. Rates may also be modified for individual risks under s. 625.13 (2). AB50,291713Section 2917. 625.15 (1) of the statutes is amended to read: AB50,1433,2114625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may 15itself establish rates and supplementary rate information for one or more market 16segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 17liability insurance, subject to s. 632.365, or the insurer may use rates and 18supplementary rate information prepared by a rate service organization, with 19average expense factors determined by the rate service organization or with such 20modification for its own expense and loss experience as the credibility of that 21experience allows. AB50,291822Section 2918. 628.34 (3) (a) of the statutes is amended to read: AB50,1434,723628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
1charging different premiums or by offering different terms of coverage except on the 2basis of classifications related to the nature and the degree of the risk covered or the 3expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, 4and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly 5among persons insured under a group, blanket or franchise policy, and terms are 6not unfairly discriminatory merely because they are more favorable than in a 7similar individual policy. AB50,29198Section 2919. 628.42 of the statutes is created to read: AB50,1434,109628.42 Disclosure and review of prior authorization requirements. 10(1) In this section: AB50,1434,1111(a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1. AB50,1434,1412(b) 1. “Prior authorization” means the process by which a health care plan or 13a contracted utilization review organization determines the medical necessity and 14medical appropriateness of otherwise covered health care services. AB50,1434,17152. “Prior authorization” includes any requirement that an enrollee or provider 16notify the health care plan or a contracted utilization review organization before, at 17the time of, or concurrent to providing a health care service. AB50,1434,1818(b) “Provider” has the meaning given in s. 628.36 (2) (a) 2. AB50,1434,2119(2) (a) A health care plan shall maintain a complete list of services for which 20prior authorization is required, including services where prior authorization is 21performed by an entity under contract with the health care plan. AB50,1434,2422(b) A health care plan shall publish the list under par. (a) on its website. The 23list shall be accessible by members of the general public without requiring the 24creation of any of an account or the entry of any credentials or personal information.
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