Amendment SA2-AB56

AB56-SA2,78,22 25. Health history and physical exams for prenatal visits and for minors.

AB56-SA2,78,24 26. Length and weight measurements for newborns and height and weight measurements for minors.

AB56-SA2,79,2 27. Head circumference and weight-for-length measurements for newborns and minors who have not attained the age of 3 years.

AB56-SA2,79,3 28. Body mass index for minors 2 years of age or older.

AB56-SA2,79,5 29. Blood pressure measurements for minors 3 years of age or older and a blood pressure risk assessment at birth.

AB56-SA2,79,7 30. Risk assessment and referral for oral health issues for minors who have attained the age of 6 months but have not attained the age of 7 years.

AB56-SA2,79,9 31. Blood screening for newborns and minors who have not attained the age of 2 months.

AB56-SA2,79,10 32. Screening for critical congenital health defects for newborns.

AB56-SA2,79,11 33. Lead screenings in accordance with sub. (10).

AB56-SA2,79,13 34. Metabolic and hemoglobin screening and screening for phenylketonuria, sickle cell anemia, and congenital hypothyroidism for minors including newborns.

AB56-SA2,79,15 35. Tuberculin skin test based on risk assessment for minors one month of age or older.

AB56-SA2,79,17 36. Tobacco counseling and cessation interventions for individuals who are 5 years of age or older.

AB56-SA2,79,19 37. Vision and hearing screening and assessment for minors including newborns.

AB56-SA2,79,21 38. Sexually transmitted infection and human immunodeficiency virus counseling for sexually active minors.

AB56-SA2,79,24 39. Risk assessment for sexually transmitted infection for minors who are 10 years of age or older and screening for sexually transmitted infection for minors who are 16 years of age or older.

AB56-SA2,79,25 40. Alcohol misuse screening and counseling for minors 11 years of age or older.

AB56-SA2,80,2 41. Autism screening for minors who have attained the age of 18 months but have not attained the age of 25 months.

AB56-SA2,80,3 42. Developmental screening and surveillance for minors including newborns.

AB56-SA2,80,4 43. Psychosocial and behavioral assessment for minors including newborns.

AB56-SA2,80,6 44. Alcohol misuse screening and counseling for pregnant adults and a risk assessment for all adults.

AB56-SA2,80,8 45. Fall prevention and counseling and preventive medication for fall prevention for community-dwelling adults 65 years of age or older.

AB56-SA2,80,9 46. Screening and counseling for intimate partner violence for adult women.

AB56-SA2,80,12 47. Well-woman visits for women who have attained the age of 18 years but have not attained the age of 65 years and well-woman visits for recommended preventive services, preconception care, and prenatal care.

AB56-SA2,80,14 48. Counseling on, consultations with a trained provider on, and equipment rental for breastfeeding for pregnant and lactating women.

AB56-SA2,80,15 49. Folic acid supplement for adult women with reproductive capacity.

AB56-SA2,80,16 50. Iron deficiency anemia screening for pregnant and lactating women.

AB56-SA2,80,18 51. Preeclampsia preventive medicine for pregnant adult women at high risk for preeclampsia.

AB56-SA2,80,20 52. Low-dose aspirin after 12 weeks of gestation for pregnant women at high risk for miscarriage, preeclampsia, or clotting disorders.

AB56-SA2,80,21 53. Screenings for hepatitis B and bacteriuria for pregnant women.

AB56-SA2,80,23 54. Screening for gonorrhea for pregnant and sexually active females 24 years of age or younger and females older than 24 years of age who are at risk for infection.

AB56-SA2,81,3 55. Screening for chlamydia for pregnant and sexually active females 24 years of age and younger and females older than 24 years of age who are at risk for infection.

AB56-SA2,81,5 56. Screening for syphilis for pregnant women and adults who are at high risk for infection.

AB56-SA2,81,8 57. Human immunodeficiency virus screening for adults who have attained the age of 15 years but have not attained the age of 66 years and individuals at high risk of infection who are younger than 15 years of age or older than 65 years of age.

AB56-SA2,81,9 58. All contraceptives and services in accordance with sub. (17).

AB56-SA2,81,11 59. Any services not already specified under this paragraph having an A or B rating in current recommendations from the U.S. preventive services task force.

AB56-SA2,81,14 60. Any preventive services not already specified under this paragraph that are recommended by the federal health resources and services administration's Bright Futures project.

AB56-SA2,81,17 61. Any immunizations, not already specified under sub. (14), that are recommended and determined to be for routine use by the federal advisory committee on immunization practices.

AB56-SA2,81,20 (c) Subject to par. (d), no disability insurance policy and no self-insured health plan may subject the coverage of any of the preventive services under par. (b) to any deductibles, copayments, or coinsurance under the policy or plan.

AB56-SA2,81,24 (d) 1. If an office visit and a preventive service specified under par. (b) are billed separately by the health care provider, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit but not on the preventive service.

AB56-SA2,82,3 2. If the primary reason for an office visit is not to obtain a preventive service, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit.

AB56-SA2,82,13 3. Except as otherwise provided in this subdivision, if a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers, the policy or plan may apply deductibles to and impose copayments or coinsurance on the office visit and the preventive service. If a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers because there is no available health care provider in the policy's or plan's network of providers that provides the preventive service, the policy or plan may not apply deductibles to or impose copayments or coinsurance on the preventive service.

AB56-SA2,82,18 4. If multiple well-woman visits described under par. (b) 47. are required to fulfill all necessary preventive services and are in accordance with clinical recommendations, the disability insurance policy or self-insured health plan may not apply a deductible to or impose a copayment or coinsurance on any of those well-woman visits.

AB56-SA2,2099i Section 2099i. 632.895 (14) (a) 1. i. and j. of the statutes are amended to read:

AB56-SA2,82,20 632.895 (14) (a) 1. i. Hepatitis A and B.

AB56-SA2,82,21 j. Varicella and herpes zoster.

AB56-SA2,2100i Section 2100i. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:

AB56-SA2,82,23 632.895 (14) (a) 1. k. Human papillomavirus.

AB56-SA2,82,24 L. Meningococcal meningitis.

AB56-SA2,82,25 m. Pneumococcal pneumonia.

AB56-SA2,83,1 n. Influenza.

AB56-SA2,83,2 o. Rotavirus.

AB56-SA2,2101i Section 2101i. 632.895 (14) (b) of the statutes is amended to read:

AB56-SA2,83,9 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for an insured or plan participant, including a dependent who is a child of the insured or plan participant.

AB56-SA2,2102i Section 2102i. 632.895 (14) (c) of the statutes is amended to read:

AB56-SA2,83,15 632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

AB56-SA2,2103i Section 2103i. 632.895 (14) (d) 3. of the statutes is amended to read:

AB56-SA2,83,19 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB56-SA2,2104i Section 2104i. 632.895 (14m) of the statutes is created to read:

AB56-SA2,83,22 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB56-SA2,84,2 (b) On a date specified by the commissioner, by rule, every disability insurance policy, except as provided in par. (g), and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB56-SA2,84,4 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB56-SA2,84,6 1. Include benefits, items, and services in, at least, all of the following categories:

AB56-SA2,84,7 a. Ambulatory patient services.

AB56-SA2,84,8 b. Emergency services.

AB56-SA2,84,9 c. Hospitalization.

AB56-SA2,84,10 d. Maternity and newborn care.

AB56-SA2,84,12 e. Mental health and substance use disorder services, including behavioral health treatment.

AB56-SA2,84,13 f. Prescription drugs.

AB56-SA2,84,14 g. Rehabilitative and habilitative services and devices.

AB56-SA2,84,15 h. Laboratory services.

AB56-SA2,84,16 i. Preventive and wellness services and chronic disease management.

AB56-SA2,84,17 j. Pediatric services, including oral and vision care.

AB56-SA2,84,22 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB56-SA2,84,24 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB56-SA2,85,2 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB56-SA2,85,6 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB56-SA2,85,9 6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB56-SA2,85,13 7. Ensure that essential health benefits established under this subsection are not subject to a coverage denial based on an insured's or plan participant's age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB56-SA2,85,20 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB56-SA2,85,25 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB56-SA2,86,2 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB56-SA2,86,7 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB56-SA2,86,11 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.

AB56-SA2,86,13 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

AB56-SA2,2105i Section 2105i. 632.895 (16m) (b) of the statutes is amended to read:

AB56-SA2,86,19 632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.

AB56-SA2,2106i Section 2106i. 632.895 (17) (b) 2. of the statutes is amended to read:

AB56-SA2,86,25 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.

AB56-SA2,2107i Section 2107i. 632.895 (17) (c) of the statutes is amended to read: