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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
15enrollees 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 enrollees
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 enrollees defined network
19plan:
AB50,1428,2220(a) Subsection (1) (c) shall apply to any of the participating providers
21providing the enrollees course of treatment under s. 609.04 (7), including the
22enrollees 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 enrollees
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 providers 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.
AB50,1435,2
1(c) The list under par. (a) is not required to contain any clinical review criteria
2applicable to the services.
AB50,1435,103(3) (a) A health care plan shall make any current prior authorization
4requirements and restrictions along with the clinical review criteria applicable to
5those requirements or restrictions accessible and conspicuously posted on its
6website to enrollees and providers. Content published by a 3rd party and licensed
7for use by a health care plan or a contracted utilization review organization may
8satisfy this subsection if it is available to access through the website of the health
9care plan or the contracted utilization review organization as long as the website
10does not unreasonably restrict access.
AB50,1435,1311(b) The prior authorization requirements and restrictions under par. (a) shall
12be described in detail, and shall be written in easily understandable, plain
13language.
AB50,1435,1614(c) The prior authorization requirements and restrictions under par. (a) shall
15indicate all of the following for each service subject to the prior authorization
16requirements and restrictions:
AB50,1435,18171. When the requirement or restriction began for policies issued or delivered
18in this state, including effective dates and any termination dates.
AB50,1435,20192. The date that the requirement or restriction was listed on the website of the
20health care plan or a contracted utilization review organization.
AB50,1435,21213. The date that the requirement or restriction was removed in this state.
AB50,1435,23224. A method to access a standardized electronic prior authorization request
23transaction process.
AB50,1436,2
1(4) Any clinical review criteria on which a prior authorization requirement or
2restriction is based shall satisfy all of the following:
AB50,1436,43(a) The criteria are based on nationally recognized, generally accepted
4standards except where provided by law.
AB50,1436,65(b) The criteria are developed in accordance with the current standards of a
6national medical accreditation entity.
AB50,1436,87(c) The criteria ensure quality of care and access to needed health care
8services.
AB50,1436,99(d) The criteria are evidence-based.
AB50,1436,1110(e) The criteria are sufficiently flexible to allow deviations from current
11standards when justified.
AB50,1436,1312(f) The criteria are evaluated and updated when necessary and no less
13frequently than once every year.
AB50,1436,1614(5) No health care plan may deny a claim for failure to obtain prior
15authorization if the prior authorization requirement was not in effect on the date
16that the service was provided.
AB50,1436,2117(6) No health care plan nor any utilization review organization contracted
18with a health care plan may deem supplies or services as incidental or deny a claim
19for supplies or services if a provided health care service associated with the
20supplies or services receives prior authorization or if a provided health care service
21associated with the supplies or services does not require prior authorization.
AB50,1437,922(7) If a health care plan intends to impose a new prior authorization
23requirement or restriction or intends to amend a prior authorization requirement
24or restriction, the health care plan shall provide all providers contracted with the

1health care plan advanced written notice of the new or amended requirement or
2restriction no less than 60 days before the new or amended requirement or
3restriction is implemented. The advanced written notice may be provided in an
4electronic format if the provider has agreed in advance to receive the notices
5electronically. No health care plan may implement a new or amended prior
6authorization requirement or restriction unless the health care plan or a contracted
7utilization review organization has updated the post on its website required under
8sub. (3) to reflect the new or amended prior authorization requirement or
9restriction.
AB50,292010Section 2920. 628.495 of the statutes is created to read:
AB50,1437,1311628.495 Pharmacy benefit management broker and consultant
12licenses. (1) Definition. In this section, pharmacy benefit manager has the
13meaning given in s. 632.865 (1) (c).
AB50,1437,1814(2) License required. Beginning on the first day of the 12th month
15beginning after the effective date of this subsection .... [LRB inserts date], no
16individual may act as a pharmacy benefit management broker or consultant and no
17individual may act to procure the services of a pharmacy benefit manager on behalf
18of a client without being licensed by the commissioner under this section.
AB50,1437,2119(3) Rules. The commissioner may promulgate rules to establish criteria and
20procedures for initial licensure and renewal of licensure and to implement licensure
21under this section.
AB50,292122Section 2921. 632.35 of the statutes is amended to read:
AB50,1438,323632.35 Prohibited rejection, cancellation and nonrenewal. No insurer
24may cancel or refuse to issue or renew an automobile insurance policy wholly or

1partially because of one or more of the following characteristics of any person: age,
2sex, residence, race, color, creed, religion, national origin, ancestry, marital status
3or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).
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