AB50: Bill Text

AB50,1424,5 2. Anesthesiology.

AB50,1424,6 3. Pathology.

AB50,1424,7 4. Radiology.

AB50,1424,8 5. Neonatology.

AB50,1424,10 6. An item or service provided by an assistant surgeon, hospitalist, or intensivist.

AB50,1424,11 7. A diagnostic service, including a radiology or laboratory service.

AB50,1424,13 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

AB50,1424,16 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.

AB50,1424,19 (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.

AB50,1424,21 (e) Any consent provided under par. (a) shall be retained by the provider for no less than 7 years.

AB50,1425,8 (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.

AB50,1426,2 (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.

AB50,1426,3 (7) Continuity of care. (a) In this subsection:

AB50,1426,4 1. “Continuing care patient” means an individual who is any of the following:

AB50,1426,6 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB50,1426,8 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB50,1426,10 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB50,1426,12 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB50,1426,14 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB50,1426,15 2. “Serious and complex condition” means any of the following:

AB50,1426,18 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.

AB50,1426,21 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.

AB50,1427,6 (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:

AB50,1427,9 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.

AB50,1427,11 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB50,1427,18 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.

AB50,1427,21 (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.

AB50,1428,6 (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.

AB50,2899 Section 2899. 609.20 (3) of the statutes is created to read:

AB50,1428,14 609.20 (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).

AB50,2900 Section 2900. 609.24 (5) of the statutes is created to read:

AB50,1428,19 609.24 (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:

AB50,1428,22 (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.

AB50,1429,2 (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.

AB50,1429,4 (c) Subsection (1) (d) may not be applied in a manner that limits the enrollee’s rights under s. 609.04 (7) (b) 3.

AB50,1429,7 (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).

AB50,2901 Section 2901. 609.40 of the statutes is created to read:

AB50,1429,10 609.40 Special enrollment period for pregnancy. Preferred provider plans and defined network plans are subject to s. 632.7498.

AB50,2902 Section 2902. 609.712 of the statutes is created to read:

AB50,1429,14 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB50,2903 Section 2903. 609.713 of the statutes is created to read:

AB50,1429,18 609.713 Qualified treatment trainee coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (7).

AB50,2904 Section 2904. 609.714 of the statutes is created to read:

AB50,1429,22 609.714 Substance abuse counselor coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (8).

AB50,2905 Section 2905. 609.718 of the statutes is created to read:

AB50,1430,2 609.718 Dental therapist coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (4e).

AB50,2906 Section 2906. 609.719 of the statutes is created to read:

AB50,1430,6 609.719 Coverage for telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB50,2907 Section 2907. 609.74 of the statutes is created to read:

AB50,1430,9 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

AB50,2908 Section 2908. 609.815 of the statutes is created to read:

AB50,1430,13 609.815 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.

AB50,2909 Section 2909. 609.823 of the statutes is created to read:

AB50,1430,17 609.823 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.

AB50,2910 Section 2910. 609.825 of the statutes is created to read:

AB50,1430,20 609.825 Coverage of emergency ambulance services. (1) In this section:

AB50,1430,21 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

AB50,1431,2 (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.

AB50,1431,7 (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:

AB50,1431,9 (a) A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.

AB50,1431,15 (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.

AB50,1431,18 (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.

AB50,1432,2 (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.

AB50,1432,6 (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.

AB50,1432,8 (5) For purposes of this section, “emergency ambulance services” does not include air ambulance services.

AB50,2911 Section 2911. 609.83 of the statutes is amended to read:

AB50,1432,13 609.83 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).

AB50,2912 Section 2912. 609.847 of the statutes is created to read:

AB50,1432,17 609.847 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.

AB50,2913 Section 2913. 611.11 (4) (a) of the statutes is amended to read:

AB50,1432,20 611.11 (4) (a) In this subsection, “municipality” has the meaning given in s. 345.05 (1) (c), but also includes any transit authority created under s. 66.1039.

AB50,2914 Section 2914. 625.12 (1) (a) of the statutes is amended to read:

AB50,1432,23 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB50,2915 Section 2915. 625.12 (1) (e) of the statutes is amended to read:

AB50,1433,2 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB50,2916 Section 2916. 625.12 (2) of the statutes is amended to read:

AB50,1433,12 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB50,2917 Section 2917. 625.15 (1) of the statutes is amended to read:

AB50,1433,21 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB50,2918 Section 2918. 628.34 (3) (a) of the statutes is amended to read:

AB50,1434,7 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB50,2919 Section 2919. 628.42 of the statutes is created to read:

AB50,1434,10 628.42 Disclosure and review of prior authorization requirements. (1) In this section:

AB50,1434,11 (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

AB50,1434,14 (b) 1. “Prior authorization” means the process by which a health care plan or a contracted utilization review organization determines the medical necessity and medical appropriateness of otherwise covered health care services.

AB50,1434,17 2. “Prior authorization” includes any requirement that an enrollee or provider notify the health care plan or a contracted utilization review organization before, at the time of, or concurrent to providing a health care service.

AB50,1434,18 (b) “Provider” has the meaning given in s. 628.36 (2) (a) 2.

AB50,1434,21 (2) (a) A health care plan shall maintain a complete list of services for which prior authorization is required, including services where prior authorization is performed by an entity under contract with the health care plan.

AB50,1434,24 (b) A health care plan shall publish the list under par. (a) on its website. The list shall be accessible by members of the general public without requiring the creation of any of an account or the entry of any credentials or personal information.