For the Infrastructure Access program, the bill does all of the following:
1. Allows a loan to a developer to provide for up to 33 percent of total project costs and a loan to a governmental unit to provide for up to 25 percent of total project costs. Under current law, a loan to developers may provide for up to 20 percent of total project costs and a loan to a governmental unit may provide for up to 10 percent of total project costs.
2. Permits up to 25 percent of the amount of a loan to a developer to be used for improvements to private infrastructure. Under current law, a loan may be used for improvements to only infrastructure that is or will be owned, maintained, or provided for or to a governmental unit or infrastructure in a rural area that is transferred to public use.
3. Allows tribal housing authorities to receive loans as developers of eligible projects.
For the Restore Main Street program, the bill does all of the following:
1. Allows a loan to provide for up to $50,000 per dwelling unit or 33 percent of total project costs, whichever is less. Under current law, a loan may provide for up to $20,000 per dwelling unit or 25 percent of total project costs, whichever is less.
2. Allows loans to be awarded to projects under the jurisdiction of a federally recognized American Indian tribe or band.
For the Vacancy-to-Vitality program, the bill does all of the following:
1. Allows a loan to provide for up to 33 percent of total project costs. Under current law, a loan may provide up to $1,000,000 per project or 20 percent of total project costs, whichever is less.
2. Permits housing developments with fewer than six dwelling units to be eligible for a loan. Under current law, an eligible housing development must have fewer than 16 dwelling units.
3. Allows loans to be awarded to projects under the jurisdiction of a federally recognized American Indian tribe or band.
In addition, the bill does the following for each of the three programs:
1. Removes the requirements that a governmental unit have updated the housing element of its comprehensive plan within five years in order to be eligible for a loan and permits projects to benefit from a tax incremental district and to use historic tax credits.
2. For the purpose of establishing that a governmental unit has reduced the costs of housing as part of applying for a loan, allows the governmental unit to submit to WHEDA measures taken by the governmental unit on or after January 1, 2015. Under current law, a governmental unit or political subdivision must show cost-reduction measures taken on or after January 1, 2023.
3. Allows a loan to be awarded for projects on tribal reservation or trust lands not subject to property taxes in this state.
Discrimination in housing based on receipt of rental or housing assistance
Current open housing law prohibits discrimination in housing based on sex; race; color; sexual orientation; disability; religion; national origin; marital status; family status; status as a victim of domestic abuse, sexual assault, or stalking; lawful source of income; age; or ancestry. The bill prohibits discrimination in housing based on receipt of rental or housing assistance in the form of a contribution from a third party.
Capital reserve fund bonding limit
Under current law, WHEDA issues notes and bonds for most WHEDA programs, including housing programs for individuals and families of low or moderate income. Current law prohibits WHEDA from issuing notes and bonds that are secured by a capital reserve fund if the total aggregate outstanding principal amount would exceed $1,000,000,000. The bill increases this limit to $1,300,000,000.
Low-income housing tax credit
Under current law, WHEDA may certify a person to claim, for a period of up to six years, a state tax credit if the person has an ownership interest in a low-income housing project in Wisconsin and qualifies for the federal low-income housing tax credit program. The bill increases the amount of credits that WHEDA may annually certify from $42,000,000 to $100,000,000. The bill also requires that the project be allocated the federal credit and financed with tax-exempt bonds that are not subject to the federal credit’s volume cap—as opposed to any tax-exempt bonds, as required under current law—and allows WHEDA to waive these requirements to the extent that WHEDA anticipates that sufficient tax-exempt private activity bond volume cap under federal law will not be available to finance low-income housing projects in any year.
Affordable housing and workforce development grants
The bill requires DOA to establish a competitive grant program to award grants to cities, villages, towns, counties, school districts, and businesses, whether operated for profit or not for profit, to fund the start-up of programs focused on developing the skilled workforce by building or rehabilitating affordable housing in their communities.
Grants to incentivize eliminating zoning barriers to affordable housing
The bill requires DOA to establish a competitive grant program to award grants to cities, villages, towns, counties, and federally recognized American Indian tribes and bands in the state that adopt one or more of the policy initiatives enumerated in the bill to eliminate zoning barriers for the creation or expansion of affordable housing.
Homeless case management services grants
Under current law, DOA may award up to 10 grants of up to $50,000 each year to shelter facilities for case management services provided to homeless families. The bill eliminates the limit on the number of grants that may be awarded and raises the grant limit to $75,000.
Geographic distribution of housing grants
Under current law, DOA may award grants to provide homeless individuals with housing and other supportive services to facilitate their movement to independent living. DOA must ensure that the funds for the grants are reasonably balanced among geographic areas of the state that correspond to the geographic areas served by each continuum of care organization designated by the federal Department of Housing and Urban Development. Under the bill, the geographic areas of the state among which DOA must balance funds for the grants need not correspond to the geographic areas served by each continuum of care organization.
Grants to Milwaukee County Housing First
The bill directs DOA to award two grants of $100,000 in fiscal years 2025–26 and 2026–27 to the Milwaukee County Department of Health and Human Services to support Milwaukee County’s Housing First initiative.
Whole-home upgrade grants
The bill establishes a pilot program under which DOA must award one or more grants to Walnut Way Conservation Corp. for the purpose of funding home improvements in low-income households in a first class city (presently only Milwaukee) that have one or more of the following goals: 1) reducing carbon emissions; 2) reducing energy burdens; 3) creating cost savings; or 4) creating healthier living environments. The bill authorizes DOA to establish eligibility requirements and other program guidelines for the grant program and allows a grant recipient to use grant moneys for administrative costs.
Housing quality standards grants
The bill requires DOA to award grants to owners of rental housing units in Wisconsin for purposes of satisfying applicable housing quality standards.
INSURANCE
Prescription Drug Affordability Review Board
The bill creates the Prescription Drug Affordability Review Board, whose purpose is to protect Wisconsin residents and other stakeholders from the high costs of prescription drugs. The board consists of the commissioner of insurance and the following members, all of whom are appointed by the governor for four-year terms:
1. Two members who represent the pharmaceutical drug industry, at least one of whom is a licensed pharmacist.
2. Two members who represent the health insurance industry.
3. Two members who represent the health care industry, at least one of whom is a licensed practitioner.
4. Two members who represent the interests of the public.
The bill requires the board to meet in open session at least four times per year to review prescription drug pricing information. The board must provide at least two weeks’ public notice of its meetings, make the meeting’s materials publicly available at least one week prior to meeting, and provide the opportunity for public comment. The bill imposes conflict of interest requirements for the board relating to recusal and public disclosure of certain conflicts. The bill directs the board to access and assess drug pricing information, to the extent practicable, by accessing and assessing information from other states, by assessing spending for the drug in Wisconsin, and by accessing other available pricing information.
Under the bill, the board must conduct drug cost affordability reviews. The first step in the reviews is for the board to identify prescription drugs whose launch wholesale acquisition cost exceeds specified thresholds, prescription drugs whose increase in wholesale acquisition cost exceeds specified thresholds, and other prescription drugs that may create affordability challenges for the health care system in Wisconsin. For each identified prescription drug, the board must determine whether to conduct an affordability review by seeking stakeholder input and considering the average patient cost share for the drug. During an affordability review, the board must determine whether use of the prescription drug that is fully consistent with the labeling approved by the federal Food and Drug Administration or standard medical practice has led or will lead to an affordability challenge for the health care system in Wisconsin. In making this determination, the bill requires the board to consider a variety of factors, which include the following:
1. The drug’s wholesale acquisition cost.
2. The average monetary price concession, discount, or rebate the manufacturer provides, or is expected to provide, for the drug to health plans.
3. The total amount of price concessions, discounts, and rebates the manufacturer provides to each pharmacy benefit manager for the drug.
4. The price at which therapeutic alternatives have been sold and the average monetary concession, discount, or rebate the manufacturer provides, or is expected to provide, to health plan payors and pharmacy benefit managers for therapeutic alternatives.
5. The costs to health plans based on patient access consistent with federal labeled indications and recognized standard medical practice.
6. The impact on patient access resulting from the drug’s cost relative to insurance benefit design.
7. The current or expected dollar value of drug-specific patient access programs that are supported by the manufacturer.
8. The relative financial impacts to health, medical, or social services costs that can be quantified and compared to baseline effects of existing therapeutic alternatives.
9. The average patient copay or other cost sharing for the drug.
If the board determines that a prescription drug will lead to an affordability challenge, the bill directs the board to establish an upper payment limit for that drug that applies to all purchases and payor reimbursements of the drug dispensed or administered to individuals in Wisconsin. In establishing the upper payment limit, the board must consider the cost of administering the drug, the cost of delivering it to consumers, and other relevant administrative costs. For certain drugs, the board must solicit information from the manufacturer regarding the price increase and, if the board determines that the price increase is not a result of the need for increased manufacturing capacity or other effort to improve patient access during a public health emergency, the board must establish an upper payment limit equal to the drug’s cost prior to the price increase.
Office of the Public Intervenor
The bill creates the Office of the Public Intervenor, attached to OCI. Under the bill, the Office of the Public Intervenor assists individuals with claims, policies, appeals, and other legal actions related to pursuing insurance coverage for medical procedures, prescription medications, and other health care services. The bill authorizes the office to levy an assessment on insurance providers based upon their premium volume for health insurance policies written in the state.
Prescription drug importation program
The bill requires the commissioner of insurance, in consultation with persons interested in the sale and pricing of prescription drugs and federal officials and agencies, to design and implement a prescription drug importation program for the benefit of and that generates savings for Wisconsin residents. The bill establishes requirements for the program, including all of the following: 1) the commissioner must designate a state agency to become a licensed wholesale distributor or contract with a licensed wholesale distributor and to seek federal certification and approval to import prescription drugs; 2) the program must comply with certain federal regulations and import from Canadian suppliers only prescription drugs that are not brand-name drugs, have fewer than four competitor drugs in this country, and for which importation creates substantial savings; 3) the commissioner must ensure that prescription drugs imported under the program are not distributed, dispensed, or sold outside of Wisconsin; and 4) the program must have an audit procedure to ensure the program complies with certain requirements specified in the bill. Before submitting the proposed program to the federal government for certification, the commissioner must submit the proposed program to JCF for its approval.
State prescription drug purchasing entity
The bill requires OCI to conduct a study on the viability of creating or implementing a state prescription drug purchasing entity.
Exemption from prior authorization requirements
The bill allows the commissioner of insurance to establish, by rule, that any health insurance policy or plan that uses a prior authorization process must 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 established by the commissioner, the health insurance policy or plan has approved or would have approved not less than a certain proportion of prior authorization requests, as established by the commissioner, submitted by the health care provider for the health care item or service. The commissioner may specify the health care items or services that may be subject to this exemption. Further, the commissioner may specify how health care providers may obtain an exemption from obtaining prior authorizations under the bill, including by providing a process for automatic evaluation.
Prior authorization transparency
The bill imposes several regulations on the use of prior authorization requirements used by health care plans. Under the bill, “prior authorization” is defined to mean 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.
The bill requires health care plans to maintain a list of services for which prior authorization is required and publish the list on its website to be accessible by members of the general public without requiring the creation of an account or the entry of any credentials or personal information. Further, the bill requires health care plans to make the current prior authorization requirements and restrictions that it uses accessible and conspicuously posted on its website or on the website of a contracted utilization review organization for enrollees and providers.
The bill provides that any clinical review criteria on which a prior authorization requirement or restriction is based must satisfy certain criteria, including that the criteria are based on nationally recognized, generally accepted standards except where provided by law, that the criteria are developed in accordance with the current standards of a national medical accreditation entity, and that the criteria ensure quality of care and access to needed health care services.
The bill prohibits a health care plan from denying a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided. Further, the bill prohibits health care plans and utilization review organizations contracted with health care plans from deeming supplies or services as incidental and from denying a claim for supplies or services if a provided health care service associated with the supplies or services receives prior authorization or if a provided health care service associated with the supplies or services does not require prior authorization.
Finally, the bill provides that if a health care plan intends to impose a new prior authorization requirement or restriction or intends to amend a prior authorization requirement or restriction, the health care plan must provide all providers contracted with the health care plan with advanced written notice of the new or amended requirement or restriction no less than 60 days before the new or amended requirement or restriction is implemented. No health care plan may implement a new or amended prior authorization requirement or restriction unless the health care plan or a contracted utilization review organization has updated the post on its website to reflect the new or amended prior authorization requirement or restriction.
Inpatient mental health prior authorization
The bill prohibits health insurance policies and self-insured governmental health plans that cover inpatient mental health services from requiring prior authorization for the provision or coverage of those services. Health insurance policies are referred to as disability insurance policies in the bill, and a self-insured governmental health plan is a self-funded health plan of the state or a county, city, village, town, or school district.
Coverage of individuals with preexisting conditions and other insurance market regulations
The bill requires certain health plans to guarantee access to coverage; prohibits plans from imposing preexisting condition exclusions; prohibits plans from setting premiums or cost-sharing amounts based on health status-related factors; prohibits plans from setting lifetime or annual limits on benefits; requires plans to cover certain essential health benefits; requires coverage of certain preventive services by plans without a cost-sharing contribution by an enrollee; sets a maximum annual amount of cost sharing for enrollees; and designates risk pool, medical loss ratio, and actuarial value requirements.
The bill requires every individual health insurance policy, referred to in the bill as health benefit plans, to accept every individual who, and every group health insurance policy to accept every employer that, applies for coverage, regardless of the sexual orientation, the gender identity, or any preexisting condition of any individual or employee who will be covered by the plan. The bill allows health benefit plans to restrict enrollment in coverage to open or special enrollment periods and requires the commissioner of insurance to establish a statewide open enrollment period that is no shorter than 30 days for every individual health benefit plan. The bill prohibits a group health insurance policy, including a self-insured governmental health plan, from imposing a preexisting condition exclusion. The bill also prohibits an individual health insurance policy from reducing or denying a claim or loss incurred or disability commencing under the policy on the ground that a disease or physical condition existed prior to the effective date of coverage.
A health benefit plan offered on the individual or small employer market or a self-insured governmental health plan may not vary premium rates for a specific plan except on the basis of 1) whether the plan covers an individual or a family; 2) the area in the state; 3) age; and 4) tobacco use, as specified in the bill. An individual health benefit plan or self-insured health plan is prohibited under the bill from establishing rules for the eligibility of any individual to enroll based on health status-related factors, which are specified in the bill. A self-insured health plan or an insurer offering an individual health benefit plan is also prohibited from requiring an enrollee to pay a greater premium, contribution, deductible, copayment, or coinsurance amount than is required of an otherwise similarly situated enrollee based on a health status-related factor. Current state law prohibits group health benefit plans from establishing rules of eligibility or requiring greater premium or contribution amounts based on a factor related to health status. The bill adds to these current law requirements for group health benefit plans that the plan may not require a greater deductible, copayment, or coinsurance amount based on a health status-related factor.
Under the bill, an individual or group health benefit plan or a self-insured governmental health plan may not establish lifetime or annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan. The bill specifies a maximum amount of cost sharing that a plan may impose as the amount calculated under the federal Patient Protection and Affordable Care Act (ACA).
The bill requires individual and small employer plans to have either a single statewide risk pool for the individual market and a single pool for the small employer market or a single statewide risk pool for a combination of the individual and small employer markets. The bill requires individual and small employer plans to have a medical loss ratio of at least 80 percent and larger group plans to have a medical loss ratio of at least 85 percent. The medical loss ratio is the proportion of premium revenues that the plan spends on clinical services and quality improvement. The bill also requires individual and small employer plans to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan. An actuarial value of 60 percent corresponds to a bronze tier plan under the ACA.
The bill requires certain health insurance policies and governmental self-insured health plans to cover essential health benefits that will be specified by the commissioner of insurance by rule. The bill specifies a list of requirements that the commissioner must follow when establishing the essential health benefits including certain limitations on cost sharing and the following general categories of benefits, items, or services in which the commissioner must require coverage: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services. If an essential health benefit specified by the commissioner is also subject to its own mandated coverage requirement, the bill requires the health insurance policy or self-insured health plan to provide coverage under whichever requirement provides the insured or plan participant with more comprehensive coverage.
The bill requires health insurance policies and governmental self-insured health plans to cover certain preventive services and to provide coverage of those preventive services without subjecting that coverage to deductibles, copayments, or coinsurance. The preventive services for which coverage is required are specified in the bill. The bill also specifies certain instances when cost-sharing amounts may be charged for an office visit associated with a preventive service.
Preventing surprise bills for emergency medical services and other items and services
The bill requires defined network plans, such as health maintenance organizations, and certain preferred provider plans and self-insured governmental plans that cover benefits or services provided in either an emergency department of a hospital or an independent freestanding emergency department to cover emergency medical services without requiring a prior authorization determination and without regard to whether the health care provider providing the emergency medical services is a participating provider or facility. If the emergency medical services for which coverage is required are provided by a nonparticipating provider, the plan must 1) not impose a prior authorization requirement or other limitation that is more restrictive than if the service was provided by a participating provider; 2) not impose cost sharing on an enrollee that is greater than the cost sharing required if the service was provided by a participating provider; 3) calculate the cost-sharing amount to be equal to the recognized amount specified under federal law; 4) provide, within 30 days of the provider’s or facility’s bill, an initial payment or denial notice to the provider or facility and then pay a total amount to the provider or facility that is equal to the amount by which an out-of-network rate exceeds the amount it received in cost sharing from the enrollee; and 5) count any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for services provided by a participating provider or facility.
For coverage of an item or service that is provided by a nonparticipating provider in a participating facility, a plan must 1) not impose a cost-sharing requirement for the item or service that is greater than the cost-sharing requirement that would have been imposed if the item or service was provided by a participating provider; 2) calculate the cost-sharing amount to be equal to the recognized amount specified under federal law; 3) provide, within 30 days of the provider’s bill, an initial payment or denial notice to the provider and then pay a total amount to the provider that is equal to the amount by which the out-of-network rate exceeds the amount it received in cost sharing from the enrollee; and 4) count any cost-sharing payment made by the enrollee for the items or services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for items or services provided by a participating provider. A nonparticipating provider providing an item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount unless the provider provides notice and obtains consent as described in the bill. However, if the nonparticipating provider is providing an ancillary item or service that is specified in the bill, and the commissioner of insurance has not specifically allowed providers to bill or hold an enrollee liable for that item or service by rule, the nonparticipating provider providing the ancillary item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount.
Under the bill, a provider or facility that is entitled to a payment for an emergency medical service or other item or service may initiate open negotiations with the defined network plan, preferred provider plan, or self-insured governmental health plan to determine the amount of payment. If the open negotiation period terminates without determination of the payment amount, the provider, facility, or plan may initiate the independent dispute resolution process as specified by the commissioner of insurance. If an enrollee of a plan is a continuing care patient, as defined in the bill, and is obtaining services from a participating provider or facility, and the contract is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract is terminated, resulting in a loss of benefits under the plan, the plan must notify the enrollee of the enrollee’s right to elect to continue transitional care, provide the enrollee an opportunity to notify the plan of the need for transitional care, and allow the enrollee to continue to have the benefits provided under the plan under the same terms and conditions as would have applied without the termination until either 90 days after the termination notice date or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.
Health insurance claims
The bill imposes upon insurers certain requirements for health insurance claims processing and denials, including a requirement to process claims within a reasonable time frame that prevents an undue delay in care, to provide a detailed explanation of a claim denial, and to disclose whether the insurer uses artificial intelligence or algorithmic decision-making in processing claims. The bill also prohibits certain actions by an insurer with respect to health insurance claims, including using vague or misleading terms to deny a claim, stalling review of a claim to avoid timely payment, allowing non-physician personnel to determine whether care is medically necessary, mandating prior approval for routine or urgent procedures in a manner that causes harmful delays, or requiring an insured to fail a cheaper treatment before approving coverage for necessary care. The bill directs insurers to annually publish a report about their claim denials for health insurance policies and their use of artificial intelligence or algorithmic decision-making in processing claims for health insurance policies. The bill also directs the commissioner of insurance to maintain a public database of insurers’ health insurance claim denial rates and the outcomes of independent reviews of adverse actions under health insurance policies.
Under current law, insureds may request an independent review of adverse actions under a health insurance policy under certain circumstances. The bill provides that an insured also has the right to request from the Office of the Public Intervenor created under the bill a review of any health insurance claim denial.
In addition, the bill authorizes the commissioner of insurance to audit insurers that deny health insurance claims with such frequency as to indicate a general business practice. Under the bill, the commissioner may collect any relevant information from an insurer necessary to conduct an audit; contract with a third party to conduct an audit; order an insurer to comply with a corrective action plan based on the findings of an audit; and impose forfeitures or sanctions on an insurer that fails to comply with a corrective action plan. The bill also requires insurers to provide a written response to any adverse findings of an audit.
Application of manufacturer discounts
Health insurance policies and plans often apply deductibles and out-of-pocket maximum amounts to the benefits covered by the policy or plan. A deductible is an amount that an enrollee in a policy or plan must pay out of pocket before attaining the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit specified by a policy or plan on the amount that an enrollee pays, and once that limit is reached, the policy or plan covers the benefit entirely. The bill requires health insurance policies that offer prescription drug benefits and self-insured health plans to apply the amount of any discounts that a manufacturer of a brand-name drug provides to reduce the amount of cost sharing that is charged to an enrollee for those brand-name drugs to the enrollee’s deductible and out-of-pocket maximum amount. That requirement applies for brand-name drugs that have no generic equivalent and for brand-name drugs that have a generic equivalent but that the enrollee has prior authorization or physician approval to obtain.
Fiduciary duty of pharmacy benefit managers
