AB50: Bill Text

AB50,2937 Section 2937. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB50,1446,16 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746, a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB50,1446,22 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB50,1447,6 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy limited duration plan subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB50,2938 Section 2938. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB50,1447,10 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5):

AB50,2939 Section 2939. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB50,1447,17 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured’s consecutive periods of coverage under the insurer’s individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB50,2940 Section 2940. 632.795 (4) (a) of the statutes is amended to read:

AB50,1448,6 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods, or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer’s policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer’s coverage terminates.

AB50,2941 Section 2941. 632.848 of the statutes is created to read:

AB50,1448,9 632.848 Exemption from prior authorization requirements. (1) In this section:

AB50,1448,12 (a) “Evaluation period” means the period of time established by the commissioner by rule that is used to evaluate whether a health care provider qualifies for an exemption from obtaining prior authorizations under sub. (2).

AB50,1448,13 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB50,1448,14 (c) “Health care item or service” includes all of the following:

AB50,1448,15 1. Prescription drugs.

AB50,1448,16 2. Laboratory testing.

AB50,1448,17 3. Medical equipment.

AB50,1448,18 4. Medical supplies.

AB50,1448,19 (d) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

AB50,1448,23 (e) “Prior authorization” means a determination by a health benefit plan, self- insured health plans, or person contracting with a health benefit plan or self- insured health plan that health care items or services proposed to be provided to a patient are medically necessary and appropriate.

AB50,1448,24 (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50,1449,8 (2) The commissioner may by rule provide that any health benefit plan or self- insured health plan that uses a prior authorization process shall exempt health care providers from obtaining prior authorizations for a health care item or service for a period of time established by the commissioner if, in the most recent evaluation period, the health benefit plan or self-insured health plan has approved or would have approved not less than the proportion of prior authorization requests established under sub. (3) submitted by the health care provider for the health care item or service.

AB50,1449,12 (3) The commissioner shall specify the proportion of prior authorization requests submitted by a health care provider that have to be approved for the health care provider to qualify for an exemption from obtaining prior authorizations under sub. (2).

AB50,1449,15 (4) The commissioner may specify by rule the health care items or services that may be subject to the exemption from obtaining prior authorizations under sub. (2).

AB50,1449,18 (5) The commissioner may specify how health care providers may obtain an exemption from obtaining prior authorizations under sub. (2) including by providing a process for automatic evaluation.

AB50,1449,20 (6) The commissioner may promulgate further rules necessary to implement this section.

AB50,2942 Section 2942. 632.851 of the statutes is created to read:

AB50,1449,23 632.851 Reimbursement of emergency ambulance services. (1) In this section:

AB50,1449,24 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

AB50,1450,4 (b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.

AB50,1450,5 (c) “Emergency medical responder” has the meaning given in s. 256.01 (4p).

AB50,1450,7 (d) “Emergency medical services practitioner” has the meaning given in s. 256.01 (5).

AB50,1450,8 (e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m.

AB50,1450,9 (f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).

AB50,1450,10 (g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c).

AB50,1450,11 (h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50,1450,17 (2) (a) A disability insurance policy or self-insured health plan shall, within 30 days after receipt of a clean claim for covered emergency ambulance services, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. No disability insurance policy or self-insured health plan may send a payment for covered emergency ambulance services to an enrollee.

AB50,1450,22 (b) A disability insurance policy or self-insured health plan shall respond to a claim for covered emergency ambulance services that is not a clean claim by sending a written notice, within 30 days after receipt of the claim, acknowledging the date of receipt of the claim and informing the ambulance service provider of one of the following:

AB50,1451,2 1. That the disability insurance policy or self-insured health plan is declining to pay all or part of the claim, including the specific reason or reasons for the denial.

AB50,1451,4 2. That additional information is necessary to determine if all or part of the claim is payable and the specific additional information that is required.

AB50,1451,9 (3) A disability insurance policy or self-insured health plan shall remit payment for the transportation of any patient by ambulance as a medically necessary emergency ambulance service if the transportation was requested by an emergency medical services practitioner, an emergency medical responder, a firefighter, a law enforcement officer, or a health care provider.

AB50,2943 Section 2943. 632.862 of the statutes is created to read:

AB50,1451,12 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB50,1451,13 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB50,1451,14 (b) “Brand name drug” means any of the following:

AB50,1451,16 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB50,1451,21 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.

AB50,1451,22 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB50,1451,23 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

AB50,1452,2 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

AB50,1452,8 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum amount and to any deductible of the disability insurance policy or self-insured health plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to the enrollee for that brand name drug.

AB50,2944 Section 2944. 632.863 of the statutes is created to read:

AB50,1452,11 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

AB50,1452,14 (a) “Health care professional” means a physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical or biologic products.

AB50,1452,16 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

AB50,1452,19 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

AB50,1453,4 (2) Licensure. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmaceutical representative in this state without being licensed by the commissioner as a pharmaceutical representative under this subsection. In order to obtain a license under this subsection, the individual shall apply to the commissioner in the form and manner prescribed by the commissioner and shall pay the fee under s. 601.31 (1) (nv). The term of a license issued under this subsection is one year, and the license is renewable.

AB50,1453,7 (3) Display of license. A pharmaceutical representative licensed under sub. (2) shall display the pharmaceutical representative’s license during each visit with a health care professional.

AB50,1453,11 (4) Enforcement. (a) Any individual who violates this section or any rules promulgated under this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day of continued violation constitutes a separate offense.

AB50,1453,16 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section or any rules promulgated under this section. A suspended or revoked license under this paragraph may not be reinstated until the pharmaceutical representative remedies all violations related to the suspension or revocation and pays all assessed penalties and fees.

AB50,1453,19 (5) Rules. The commissioner shall promulgate rules to implement this section, including rules that require pharmaceutical representatives to complete continuing educational coursework as a condition of licensure.

AB50,2945 Section 2945. 632.864 of the statutes is created to read:

AB50,1453,22 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

AB50,1453,23 (a) “Administrative service” means any of the following:

AB50,1454,1 1. Assisting with claims.

AB50,1454,2 2. Assisting with audits.

AB50,1454,3 3. Providing centralized payment.

AB50,1454,4 4. Performing certification in a specialized care program.

AB50,1454,5 5. Providing compliance support.

AB50,1454,6 6. Setting flat fees for generic drugs.

AB50,1454,7 7. Assisting with store layout.

AB50,1454,8 8. Managing inventory.

AB50,1454,9 9. Providing marketing support.

AB50,1454,11 10. Providing management and analysis of payment and drug dispensing data.

AB50,1454,12 11. Providing resources for retail cash cards.

AB50,1454,15 (b) “Independent pharmacy” means a pharmacy operating in this state that is licensed under s. 450.06 or 450.065 and is under common ownership with no more than 2 other pharmacies.

AB50,1454,16 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB50,1454,18 (d) “Pharmacy services administrative organization” means an entity operating in this state that does all of the following:

AB50,1454,20 1. Contracts with an independent pharmacy to conduct business with a 3rd- party payer on the independent pharmacy’s behalf.

AB50,1454,23 2. Provides at least one administrative service to an independent pharmacy and negotiates and enters into a contract with a 3rd-party payer or pharmacy benefit manager on behalf of the independent pharmacy.

AB50,1455,3 (e) “Third-party payer” means an entity, including a plan sponsor, health maintenance organization, or insurer, operating in this state that pays or insures health, medical, or prescription drug expenses on behalf of beneficiaries.

AB50,1455,10 (2) Licensure. (a) Beginning on the first day of the 12th month beginning after the effective date of this paragraph .... [LRB inserts date], no person may operate as a pharmacy services administrative organization without being licensed by the commissioner as a pharmacy services administrative organization under this subsection. In order to obtain a license under this paragraph, the person shall apply to the commissioner in the form and manner prescribed by the commissioner. The application for licensure under this paragraph shall include all of the following:

AB50,1455,12 1. The name, address, telephone number, and federal employer identification number of the applicant.

AB50,1455,14 2. The name, business address, and telephone number of a contact person for the applicant.

AB50,1455,15 3. The fee under s. 601.31 (1) (nw).

AB50,1455,16 4. Evidence of financial responsibility of at least $1,000,000.

AB50,1455,17 5. Any other information required by the commissioner.

AB50,1455,19 (b) The term of a license issued under par. (a) shall be 2 years from the date of issuance.