Short-term, limited duration plan coverage requirements
The bill sets certain coverage requirements on individual health plans that are short-term, limited duration plans. Under current law, a short-term, limited duration plan is individual health benefit plan coverage that is marketed and designed to provide short-term coverage as a bridge between other coverages and that has a term of not more than 12 months and an aggregate term of all consecutive periods of coverage that does not exceed 18 months. Under current law, an insurer generally must renew individual health coverage at the option of the insured, but an insurer is not required to renew a short-term, limited duration plan.
The bill requires an insurer that offers a short-term, limited duration plan to accept every individual who applies for coverage, regardless of whether the individual has a preexisting condition. The bill also prohibits a short-term, limited duration plan from imposing a preexisting condition exclusion. Under current law, a short-term, limited duration plan may impose a preexisting condition exclusion, but the plan must reduce the length of time of the exclusion by the aggregate duration of the insured’s consecutive periods of coverage. Under current law, a preexisting condition exclusion is a period of time during which a plan will not cover a medical condition for which the insured received some medical attention before the effective date of coverage.
Under the bill, an insurer that offers a short-term, limited duration 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 insurer that offers a short-term, limited duration plan is prohibited under the bill from establishing rules for the eligibility of any individual to enroll based on certain health status-related factors, which are specified in the bill, and from requiring an enrollee to pay a greater premium, contribution, deductible, copayment, or coinsurance amount than is required of a similarly situated enrollee based on a health status-related factor. Under the bill, a short-term, limited duration plan may not establish lifetime limits or limits for the duration of the coverage on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.
Finally, the bill reduces the maximum allowable term of a short-term, limited duration plan from 12 months to three months and reduces the maximum aggregate duration from 18 months to six months.
Special enrollment period for pregnancy
The bill requires health insurance plans and self-insured governmental health plans to allow a pregnant individual who is eligible for coverage under the plan, and any individual who is eligible for coverage because of a relationship to the pregnant individual, to enroll in the plan at any time during the pregnancy. Under the bill, the coverage must begin no later than the first day of the first calendar month in which the pregnant individual receives medical verification of the pregnancy, except that the pregnant individual may direct coverage to begin on the first day of any month occurring during the pregnancy. The bill also requires that insurers offering group health insurance coverage notify individuals of the special enrollment period at or before the time the individual is initially offered the opportunity to enroll in the plan.
Coverage of infertility services
The bill requires health insurance policies and self-insured governmental health plans that cover medical or hospital expenses to cover diagnosis of and treatment for infertility and standard fertility preservation services. Coverage required under the bill must include at least four completed egg retrievals with unlimited embryo transfers, in accordance with certain guidelines, and single embryo transfer when recommended and medically appropriate. Policies and plans may not impose an exclusion, limitation, or other restriction on the coverage required under the bill on the basis that an insured person participates in fertility services provided by or to a third party. Policies and plans are also prohibited from imposing an exclusion, limitation, or other restriction on coverage of medications for which the bill requires coverage that is not imposed on any other prescription medications covered under the policy or plan. Similarly, policies and plans may not impose any exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period, or other restriction on diagnosis, treatment, or services for which coverage is required under the bill that is different from any exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period, or other restriction imposed on benefits for other services.
Coverage of over-the-counter oral contraceptives
Under current law, every health insurance policy and every self-insured governmental health plan that covers outpatient health care services, preventive treatments and services, or prescription drugs and devices must provide coverage for contraceptives prescribed by a health care provider. Under the bill, these insurance policies and health plans must also provide coverage of oral contraceptives that are lawfully furnished over the counter without a prescription.
Reimbursement to federal drug pricing program participants
The bill prohibits any person from reimbursing certain entities that participate in the federal drug pricing program, known as the 340B Program, for a drug subject to an agreement under the program at a rate lower than that paid for the same drug to pharmacies that have a similar prescription volume. The bill also prohibits a person from imposing any fee, charge back, or other adjustment on the basis of the entity’s participation in the 340B Program. The entities covered by the prohibitions under the bill are federally qualified health centers, critical access hospitals, and grantees under the federal Ryan White HIV/AIDS Program, as well as these entities’ pharmacies and any pharmacy with which any of the entities have contracted to dispense drugs through the 340B Program. The bill allows the commissioner of insurance to promulgate rules to establish minimum reimbursement rates for entities that participate in the 340B Program.
Reimbursement for emergency ambulance services under health insurance policies and plans
The bill makes several changes to the coverage and reimbursement of emergency ambulance services under health insurance policies and plans. First, the bill requires defined network plans, preferred provider plans, and self-insured governmental plans that provide coverage of emergency medical services to cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is the greatest of 1) a rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated; 2) 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 for the Medicare program 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; or 3) 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. The bill prohibits any defined network plan, preferred provider plan, or self-insured governmental plan from imposing 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. The bill provides that no ambulance service provider that receives reimbursement as provided in the bill may charge 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. Finally, the bill provides that any health insurance policy or self-insured governmental health plan must respond to claims for covered emergency ambulance services within 30 days after receipt of the claim and, if the claim is without defect, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. If the claim has a defect, the bill instead requires the health insurance policy or self-insured governmental health plan to provide a written notice to the ambulance service provider within 30 days after receipt of the claim.
Coverage of treatment or services provided by qualified treatment trainees
The bill prohibits any health insurance plan from excluding coverage for mental health or behavioral health treatment or services provided by a qualified treatment trainee within the scope of the qualified treatment trainee’s education and training if the health insurance plan covers the mental health or behavioral health treatment or services when provided by another health care provider. “Qualified treatment trainee” is defined under current law to mean either a graduate student who is enrolled in an accredited institution in psychology, counseling, marriage and family therapy, social work, nursing, or a closely related field or a person with a graduate degree from an accredited institution and course work in psychology, counseling, marriage and family therapy, social work, nursing, or a closely related field who has not yet completed the applicable supervised practice requirements described under the administrative code.
Coverage of treatment or services provided by substance abuse counselors
The bill prohibits any health insurance plan from excluding coverage for alcoholism or other drug abuse treatment or services provided by a certified substance abuse counselor within the scope of the substance abuse counselor’s education and training if the health insurance plan covers the alcoholism or other drug abuse treatment or services when provided by another health care provider. “Substance abuse counselor” is defined under current law to mean a substance abuse counselor-in-training, a substance abuse counselor, or a clinical substance abuse counselor.
Coverage of services, treatment, or procedures provided by dental therapists
Current law prohibits any health insurance plan from excluding coverage for diagnosis and treatment of a condition or complaint by a dental therapist within the scope of the dental therapist’s license if the health insurance plan covers diagnosis and treatment of the condition or complaint by another health care provider. The bill instead prohibits any health insurance plan from excluding coverage for dental services, treatment, or procedures provided by a dental therapist within the scope of the dental therapist’s license if the health insurance plan covers the dental services, treatment, or procedures when provided by another health care provider. “Dental therapist” is defined under current law as an individual who engages in the limited practice of dentistry.
Cost-sharing cap on insulin
The bill prohibits every health insurance policy and governmental self-insured health plan that covers insulin and imposes cost sharing on prescription drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a one-month supply. Current law requires every health insurance policy that provides coverage of expenses incurred for treatment of diabetes to provide coverage for specified expenses and items, including insulin. The required coverage under current law for certain diabetes treatments other than insulin infusion pumps is subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy as other covered expenses. The bill’s cost-sharing limitation on insulin supersedes the specification that the exclusions, limitations, deductibles, and coinsurance are the same as for other coverage.
Insulin safety net programs
The bill requires insulin manufacturers to establish a program under which qualifying Wisconsin residents who are in urgent need of insulin and are uninsured or have limited insurance coverage can be dispensed insulin at a pharmacy. Under the program, if a qualifying individual in urgent need of insulin provides a pharmacy with a form attesting that the individual meets the program’s eligibility requirements, specified proof of residency, and a valid insulin prescription, the pharmacy must dispense a 30-day supply of insulin to the individual and may charge the individual a copayment of no more than $35. The pharmacy may submit an electronic payment claim for the insulin’s acquisition cost to the manufacturer or agree to receive a replacement of the same insulin in the amount dispensed.
The bill also requires that each insulin manufacturer establish a patient assistance program to make insulin available to any qualifying Wisconsin resident who, among other requirements, is uninsured or has limited insurance coverage and whose family income does not exceed 400 percent of the federal poverty line. Under the bill, an individual must apply to participate in a manufacturer’s program. If the manufacturer determines that the individual meets the program’s eligibility requirements, the manufacturer must issue the individual a statement of eligibility, which is valid for 12 months and may be renewed. Under the bill, if an individual with a statement of eligibility and valid insulin prescription requests insulin from a pharmacy, the pharmacy must submit an order to the manufacturer, who must then provide a 90-day supply of insulin at no charge to the individual or pharmacy. The pharmacy may charge the individual a copayment of no more than $50. Under the bill, a manufacturer is not required to issue a statement of eligibility if the individual has prescription drug coverage through an individual or group health plan and the manufacturer determines that the individual’s insulin needs are better addressed through the manufacturer’s copayment assistance program. In such case, the manufacturer must provide the individual with the necessary drug coupons, and the individual may not be required to pay more than a $50 copayment for a 90-day supply of insulin.
Under the bill, if the manufacturer determines that an individual is not eligible for the patient assistance program, the individual may file an appeal with OCI. The bill directs OCI to establish procedures for deciding appeals. Under the bill, OCI must issue a decision within 10 days, and that decision is final.
The bill requires that insulin manufacturers annually report to OCI certain information, including the number of individuals served and the cost of insulin dispensed under the programs and that OCI annually report to the governor and the legislature on the programs. The bill also directs OCI to conduct public outreach and develop an information sheet about the programs, conduct satisfaction surveys of individuals and pharmacies that participate in the programs, and report to the governor and the legislature on the surveys by July 1, 2028. Additionally, the bill requires that OCI develop a training program for health care navigators to assist individuals in accessing appropriate long-term insulin options and maintain a list of trained navigators.
The bill provides that a manufacturer that violates the bill’s provisions may be required to forfeit not more than $200,000 per month of violation, which increases to $400,000 per month if the manufacturer continues to be in violation after six months and to $600,000 per month if the manufacturer continues to be in violation after one year. The bill’s requirements do not apply to manufacturers with annual insulin sales revenue in Wisconsin of no more than $2,000,000 or to insulin that costs less than a specified dollar amount.
Value-based diabetes medication pilot project
The bill directs OCI to develop a pilot project under which a pharmacy benefit manager and a pharmaceutical manufacturer are directed to create a value-based, sole-source arrangement to reduce the costs of prescription diabetes medication. The bill allows OCI to promulgate rules to implement the pilot project.
Funding for health insurance navigators
The bill directs the commissioner of insurance to award $500,000 in fiscal year 2025-26 and $500,000 in fiscal year 2026-27 to a licensed navigator to prioritize services for the direct care workforce population. Navigators are individuals or entities that perform certain duties, including conducting public education activities to raise awareness of the availability of qualified health plans, distributing fair and impartial information concerning enrollment in qualified health plans, facilitating enrollment in qualified health plans, and providing referrals for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage.
Health Insurance Risk-Sharing Plan balance transfer
The Health Insurance Risk-Sharing Plan (HIRSP) provided health insurance coverage in individual policies to certain eligible individuals, including individuals who were refused coverage in the private health insurance market because of their mental or physical condition. HIRSP was dissolved and, by March 31, 2014, all coverage under HIRSP was finally terminated. 2015 Wisconsin Act 55 repealed two appropriations to OCI that provided funding for the affairs of HIRSP and for winding up the affairs of HIRSP. The bill transfers any balance that was credited to those appropriations and not lapsed as a result of 2015 Wisconsin Act 55 to the general program operations appropriation for OCI in fiscal year 2025-26. Wisconsin Healthcare Stability Plan spending limit
Under current law, the Wisconsin Healthcare Stability Plan (WIHSP) makes a reinsurance payment to a health insurance carrier if the claims for an individual who is enrolled in a health benefit plan with that carrier exceed a threshold amount in a benefit year. WIHSP is administered by OCI and operates under specific terms and conditions of a waiver agreement between OCI and the federal Department of Health and Human Services, which was dated July 29, 2018, and extended December 1, 2022. Currently, the commissioner of insurance is limited to spending $230,000,000 for WIHSP from all revenue sources in a year, unless JCF increases the amount. Under the bill, the governor, not JCF, may increase the spending limit. In addition, the bill increases the spending limit to $250,000,000 in 2026, and beginning in 2027, the bill directs the commissioner to annually adjust the spending limit based on the increase, if any, in the medical care index of the consumer price index. The bill also specifies that OCI’s authority includes the authority to operate WIHSP under any waiver extension approvals.
JUSTICE
Powers of the attorney general
The bill repeals changes made to the powers of the attorney general in 2017 Wisconsin Act 369 relating to the power to compromise or discontinue civil actions prosecuted by DOJ and the power to compromise and settle actions in cases where DOJ is defending the state. The bill reestablishes these settlement powers as they existed under the law before 2017 Wisconsin Act 369 was enacted. The bill allows the attorney general to compromise or discontinue actions prosecuted by DOJ 1) when directed by the officer, department, board, or commission that directed the prosecution or 2) with the approval of the governor when the action is prosecuted by DOJ on the initiative of the attorney general or at the request of any individual. The bill eliminates the requirement for approval of a compromise or discontinuance from a legislative intervenor or JCF. It also eliminates the requirement for the attorney general to obtain approval of a compromise or discontinuance by the Joint Committee on Legislative Organization (JLCO) in certain circumstances before submitting a proposed plan to JCF.
Under the bill, when DOJ is defending the state, the attorney general may compromise and settle the action as the attorney general determines to be in the best interest of the state. The bill eliminates the requirement under current law that, in actions for injunctive relief or if there is a proposed consent decree, the attorney general must 1) obtain the approval of any legislative intervenor or 2) if there is no intervenor, submit a proposed plan to JCF and, in certain circumstances, obtain approval of JCF. The bill also eliminates the requirement for the attorney general to obtain approval from JCLO in certain circumstances before submitting a proposed plan of settlement or compromise to JCF.
Crime victim services grants
Current law provides for a number of surcharges that a court must impose on a person who is found to have committed crimes or violated ordinances. The bill creates a new crime victim services surcharge and requires a court to impose the surcharge when imposing a sentence, a period of probation, or a civil forfeiture on a person. The amount of the surcharge is the sum of 40 percent of any fine or forfeiture imposed or $40, whichever is greater, plus $50 for each conviction of a misdemeanor or felony.
The bill requires DOJ to use the funds collected from the surcharge to award grants to organizations that are eligible for federal funds to provide crime victim assistance. The grants from DOJ are intended to supplement any federal funds. In addition, the bill authorizes DOA to supplement the funds available for the grants if DOA determines that the amounts available are insufficient for crime victim services. Under the bill, if DOA determines the amounts available are insufficient, the amount that may be supplemented is capped at the difference between $44,500,000 and the sum of the federal funds received in that fiscal year for crime victim assistance plus the funds collected in that fiscal year from the crime victim services surcharge created in the bill.
Alternatives to prosecution and incarceration programs
Under current law, DOJ operates the alternatives to incarceration grant program and the drug courts grant program. Under these programs, DOJ provides grants to counties and tribes for providing alternatives to prosecution and incarceration for persons who abuse alcohol or other drugs and diverting substance-abusing persons from prison or jail into treatment.
Under the bill, December 31, 2026, is the last day these DOJ grant programs will be in effect. Beginning on January 1, 2027, DOA will operate a grant program for tribes to provide alternatives to prosecution and incarceration programs, and counties will be required to operate such programs to be eligible for certain circuit court payments from the director of state courts.
The bill also transfers 3.0 FTE GPR positions that administer the alternatives to incarceration grant program, and the incumbent employees holding those positions, from DOJ to the Wisconsin Supreme Court on January 1, 2027.
Eliminating the sunset on funding for the Office of School Safety
2023 Wisconsin Act 240 increased the number of positions for the Office of School Safety (OSS) in DOJ by 14.2 project positions for the period beginning on January 1, 2025, and ending on October 1, 2025, and allowed, for the same period, DOJ to fund the positions and other OSS duties using the fees that DOJ collects for issuing licenses to carry concealed weapons. The bill eliminates the sunset on using the fees so that DOJ may continue using the fees to fund positions and other OSS duties. Law enforcement officer training requirements
The bill provides that the Law Enforcement Standards Board may not prevent noncitizens who are in receipt of valid employment authorization from the federal Department of Homeland Security from participating in a law enforcement preparatory training program.
Project employees of DOJ offices under ARPA
The bill provides that individuals who are in project positions that were funded by the American Rescue Plan Act of 2021 and who are employed by DOJ may be appointed to equivalent permanent positions at DOJ without going through the civil service hiring process as new hires.
Appropriation for restitution moneys
The bill makes a technical change to DOJ’s restitution appropriation to provide that it also includes all moneys received by DOJ under any other unspecified court order or settlement agreement for the purpose of providing restitution to victims.
Project attorney reporting requirement
2017 Wisconsin Act 261 created two field prosecutor attorney project positions to assist DOJ’s Division of Criminal Investigation and provided that those positions would terminate five years after the effective date of the act. The act also created a requirement that DOJ submit an annual report to JCF describing the activities and effectiveness of those field prosecutor attorneys. Those positions have expired. The bill eliminates the reporting requirement relating to those expired field prosecutor attorney project positions.
Law enforcement officer training reimbursement
The bill makes a technical change relating to the appropriations from which reimbursements for law enforcement officer training are paid.
Relator appropriation
The bill creates a continuing appropriation to hold all moneys received by DOJ that is owed to a relator, to provide payments to relators. A relator is a type of party in a legal action in whose name an action is brought by a state.
Gifts and grants and disposition of settlement funds
The bill repeals certain changes made by 2017 Wisconsin Act 369 relating to gifts and grants and certain proceeds received by DOJ, specifically reversing provisions that changed a DOJ gifts and grants appropriation and a DOJ gifts, grants, and proceeds appropriation from continuing appropriations to annual appropriations. The bill also repeals the requirement that the attorney general must deposit all settlement funds into the general fund. The bill restores procedures relating to discretionary settlement funds under which the attorney general could expend certain settlement funds not committed under the terms of a settlement after submitting a plan to JCF for passive review only if either 1) the cochairpersons of JCF do not schedule a meeting or 2) a meeting is scheduled and JCF approves a plan for expenditure.
LOCAL GOVERNMENT
General local government
Local landlord-tenant ordinances
Current law prohibits political subdivisions from enacting certain ordinances relating to landlords and tenants. Political subdivisions may not do any of the following:
1. Prohibit or limit landlords from obtaining or using certain information relating to a tenant or prospective tenant, including monthly household income, occupation, rental history, credit information, court records, and social security numbers.
2. Limit how far back in time a landlord may look at a prospective tenant’s credit information, conviction record, or previous housing.
3. Prohibit or limit a landlord from entering into a rental agreement with a prospective tenant while the premises are occupied by a current tenant.
4. Prohibit or limit a landlord from showing a premises to a prospective tenant during a current tenant’s tenancy.
5. Place requirements on a landlord with respect to security deposits or earnest money or inspections that are in addition to what is required under administrative rules.
6. Limit a tenant’s responsibility for any damage to or neglect of the premises.
7. Require a landlord to provide to tenants or to the political subdivision any information that is not required to be provided under federal or state law.
8. Require a residential property to be inspected except under certain circumstances.
9. Impose an occupancy or transfer of tenancy fee on a rental unit.
Current law also prohibits political subdivisions from regulating rent abatement in a way that permits abatement for conditions other than those that materially affect the health or safety of the tenant or that substantially affect the use and occupancy of the premises. The bill eliminates all of these prohibitions.
Local moratorium on evictions
Current law prohibits political subdivisions from imposing a moratorium on landlords from pursuing eviction actions against a tenant. The bill eliminates that prohibition.
Rental property inspection requirements
The bill makes various changes to the requirements relating to inspections of rental properties. The bill eliminates existing limitations on inspection fees that political subdivisions may charge for rental property inspections. Under the bill, a landlord must provide notice to a tenant of an impending inspection in the same manner the landlord would provide notice under current law to enter for repairs or to show the property to prospective tenants. The bill also provides that rental property inspection fees charged by a political subdivision are not subject to deduction from the political subdivision’s tax levy.
Local government civil service system and grievance procedure requirements
The bill modifies the requirements for any grievance system established by local governmental units, including adding a requirement for any civil service system or grievance procedure to include a just cause standard of review for employee terminations. Under current law, a local governmental unit that did not have a civil service system before June 29, 2011, must have established a grievance system. In order to comply with the requirement to have established a grievance system, a local governmental unit may establish either 1) a civil service system under any provision authorized by law, to the greatest extent practicable, if no specific provision for creation of a civil service system applies to the governmental unit or 2) a grievance procedure as set forth in the statutes. Current law requires that any civil service system established or grievance procedure created must contain a grievance procedure that addresses employee terminations, employee discipline, and workplace safety. The bill does not eliminate the requirement for these provisions but instead adds a requirement for a provision relating to a just cause standard of review for employee terminations, including a refusal to renew a teaching contract.
Current law also requires that if a local governmental unit creates a grievance procedure, the procedure must contain certain elements, including a written document specifying the process that a grievant and an employer must follow; a hearing before an impartial hearing officer; and an appeal process in which the highest level of appeal is the governing body of the local governmental unit. The bill provides that the hearing officer must be from the Wisconsin Employment Relations Commission and adds the following two additional required elements in the grievance procedure: 1) a provision indicating the grievant is entitled to representation throughout the grievance process and 2) a provision indicating that the employer must bear all fees and costs related to the grievance process, except the grievant’s representational fees and costs.
Local employment regulations
