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AB68-ASA2-AA2,69,2421 b. Pays to the provider or facility a total amount that, incorporating any initial
22payment under subd. 4. a., is equal to the amount by which the rate for a provider
23or facility that is not a participating provider or facility exceeds the cost-sharing
24amount.
AB68-ASA2-AA2,70,5
15. The plan counts any cost-sharing payment made by the enrollee for the
2emergency medical services toward any in-network deductible or out-of-pocket
3maximum applied by the plan in the same manner as if the cost-sharing payment
4was made for an emergency medical service provided by a participating provider or
5in a participating facility.
AB68-ASA2-AA2,70,16 6(3) Provider billing limitation for emergency medical services; ambulance
7services.
A provider of emergency medical services or a facility in which emergency
8medical services are provided that is entitled to payment under sub. (2) may not bill
9or hold liable an enrollee for any amount for the emergency medical service that is
10more than the cost-sharing amount determined under sub. (2) (c) 3. for the
11emergency service. A provider of ambulance services that is not a participating
12provider under an enrollee's defined network plan, preferred provider plan, or
13self-insured governmental plan may not bill or hold liable an enrollee for any
14amount of the ambulance service that is more than the cost-sharing amount that the
15enrollee would be charged if the provider of ambulance services was a participating
16provider under the enrollee's plan.
AB68-ASA2-AA2,70,22 17(4) Nonparticipating provider in participating facility. For items or services
18other than emergency medical services that are provided to an enrollee of a defined
19network plan, preferred provider plan, or self-insured governmental plan by a
20provider who is not a participating provider but who is providing services at a
21participating facility, the plan shall provide coverage for the item or service in
22accordance with all of the following:
AB68-ASA2-AA2,70,2523 (a) The plan may not impose on an enrollee a cost-sharing requirement for the
24item or service that is greater than the cost-sharing requirement that would have
25been imposed if the item or service was provided by a participating provider.
AB68-ASA2-AA2,71,4
1(b) Any cost-sharing amount imposed on an enrollee for the item or service is
2calculated as if the total amount that would have been charged for the item or service
3if provided by a participating provider is equal to the amount paid to the provider
4that is not a participating provider as determined by the commissioner.
AB68-ASA2-AA2,71,65 (c) No later than 30 days after the provider transmits the bill for services, the
6plan shall send to the provider an initial payment or a notice of denial of payment.
AB68-ASA2-AA2,71,107 (d) The plan shall make a total payment directly to the provider that provided
8the item or service to the enrollee that, added to any initial payment described under
9par. (c), is equal to the amount by which the out-of-network rate for the item or
10service exceeds the cost-sharing amount.
AB68-ASA2-AA2,71,1411 (e) The plan counts any cost-sharing payment made by the enrollee for the item
12or service toward any in-network deductible or out-of-pocket maximum applied by
13the plan in the same manner as if the cost-sharing payment was made for the item
14or service when provided by a participating provider.
AB68-ASA2-AA2,71,20 15(5) Charging for services by nonparticipating provider; notice and consent.
16(a) Except as provided in par. (c), a provider of an item or service that is entitled to
17payment under sub. (4) may not bill or hold liable an enrollee for any amount for the
18item or service that is more than the cost-sharing amount determined under sub. (4)
19(b) for the item or service unless the nonparticipating provider provides notice and
20obtains consent in accordance with all of the following:
AB68-ASA2-AA2,71,2321 1. The notice states that the provider is not a participating provider in the
22enrollee's defined network plan, preferred provider plan, or self-insured
23governmental plan.
AB68-ASA2-AA2,72,224 2. The notice provides a good faith estimate of the amount that the provider
25may charge the enrollee for the item or service involved, including notification that

1the estimate does not constitute a contract with respect to the charges estimated for
2the item or service.
AB68-ASA2-AA2,72,53 3. The notice includes a list of the participating providers at the facility that
4would be able to provide the item or service and notification that the enrollee may
5be referred to one of those participating providers.
AB68-ASA2-AA2,72,86 4. The notice includes information about whether or not prior authorization or
7other care management limitations may be required before receiving an item or
8service at the participating facility.
AB68-ASA2-AA2,72,139 5. The enrollee provides consent to the provider to be treated by the
10nonparticipating provider, and the consent acknowledges that the enrollee has been
11informed that the charge paid by the enrollee may not meet a limitation that the
12enrollee's defined network plan, preferred provider plan, or self-insured
13governmental plan places on cost sharing, such as an in-network deductible.
AB68-ASA2-AA2,72,1514 6. A signed copy of the consent described under subd. 5. is provided to the
15enrollee.
AB68-ASA2-AA2,72,1716 (b) To be considered adequate, the notice and consent under par. (a) shall meet
17one of the following requirements, as applicable:
AB68-ASA2-AA2,72,2118 1. If the enrollee makes an appointment for the item or service at least 72 hours
19before the day on which the item or service is to be provided, any notice under par.
20(a) shall be provided to the enrollee at least 72 hours before the day of the
21appointment at which the item or service is to be provided.
AB68-ASA2-AA2,72,2422 2. If the enrollee makes an appointment for the item or service less than 72
23hours before the day on which the item or service is to be provided, any notice under
24par. (a) shall be provided to the enrollee on the day that the appointment is made.
AB68-ASA2-AA2,73,6
1(c) A provider of an item or service that is entitled to payment under sub. (4)
2may not bill or hold liable an enrollee for any amount for the ancillary item or service
3that is more than the cost-sharing amount determined under sub. (4) (b) for the item
4or service, unless the commissioner specifies by rule that the provider may balance
5bill for the specified item or service, if the ancillary item or service is any of the
6following:
AB68-ASA2-AA2,73,77 1. Related to an emergency medical service.
AB68-ASA2-AA2,73,88 2. Anesthesiology.
AB68-ASA2-AA2,73,99 3. Pathology.
AB68-ASA2-AA2,73,1010 4. Radiology.
AB68-ASA2-AA2,73,1111 5. Neonatology.
AB68-ASA2-AA2,73,1212 6. A item or service provided by an assistant surgeon, hospitalist, or intensivist.
AB68-ASA2-AA2,73,1313 7. Diagnostic service, including a radiology or laboratory service.
AB68-ASA2-AA2,73,1514 8. An item or service provided by a specialty practitioner that the commissioner
15specifies by rule.
AB68-ASA2-AA2,73,1816 9. An item or service provided by a nonparticipating provider when there is no
17participating provider who can furnish the item or service at the participating
18facility.
AB68-ASA2-AA2,74,3 19(6) Notice by provider or facility. Beginning no later than January 1, 2022,
20a health care provider or health care facility shall make available, including posting
21on an Internet site, to enrollees in defined network plans, preferred provider plans,
22and self-insured governmental plans notice of the requirements on a provider or
23facility under subs. (3) and (5), of any other applicable state law requirements on the
24provider or facility with respect to charging an enrollee for an item or service if the
25provider or facility does not have a contractual relationship with the plan, and of

1information on contacting appropriate state or federal agencies in the event the
2enrollee believes the provider or facility violates any of the requirements under this
3section or other applicable law.
AB68-ASA2-AA2,74,20 4(7) Negotiation; dispute resolution. A provider or facility that is entitled to
5receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (4) (c) may
6initiate, within 30 days of receiving the initial payment or notice of denial, open
7negotiations with the defined network plan, preferred provider plan, or self-insured
8governmental plan to determine a payment amount for the emergency medical
9service or other item or service for a period that terminates 30 days after initiating
10open negotiations. If the open negotiation period under this subsection terminates
11without determination of a payment amount, the provider, facility, defined network
12plan, preferred provider plan, or self-insured governmental plan may initiate,
13within the 4 days beginning on the day after the open negotiation period ends, the
14independent dispute resolution process as specified by the commissioner. If the
15independent dispute resolution decision maker determines the payment amount,
16the party to the independent dispute resolution process whose amount was not
17selected shall pay the fees for the independent dispute resolution. If the parties to
18the independent dispute resolution reach a settlement on the payment amount, the
19parties to the independent dispute resolution shall equally divide the payment for
20the fees for the independent dispute resolution.
AB68-ASA2-AA2,74,21 21(8) Continuity of care. (a) In this subsection:
AB68-ASA2-AA2,74,2222 1. “Continuing care patient” means an individual who is any of the following:
AB68-ASA2-AA2,74,2423 a. Undergoing a course of treatment for a serious and complex condition from
24a provider or facility.
AB68-ASA2-AA2,75,2
1b. Undergoing a course of institutional or inpatient care from a provider or
2facility.
AB68-ASA2-AA2,75,43 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
4care, from a provider or facility.
AB68-ASA2-AA2,75,65 d. Pregnant and undergoing a course of treatment for the pregnancy from a
6provider or facility.
AB68-ASA2-AA2,75,87 e. Terminally ill and receiving treatment for the illness from a provider or
8facility.
AB68-ASA2-AA2,75,99 2. “Serious and complex condition” means any of the following:
AB68-ASA2-AA2,75,1210 a. In the case of an acute illness, a condition that is serious enough to require
11specialized medical treatment to avoid the reasonable possibility of death or
12permanent harm.
AB68-ASA2-AA2,75,1513 b. In the case of a chronic illness or condition, a condition that is
14life-threatening, degenerative, potentially disabling, or congenital and requires
15specialized medical care over a prolonged period of time.
AB68-ASA2-AA2,75,2116 (b) If an enrollee is a continuing care patient and is obtaining items or services
17from a participating provider or facility and the contract between the defined
18network plan, preferred provider plan, or self-insured governmental plan and the
19participating provider or facility is terminated or the coverage of benefits that
20include the items or services provided by the participating provider or facility are
21terminated by the plan, the plan shall do all of the following:
AB68-ASA2-AA2,75,2422 1. Notify each enrollee of the termination of the contract or benefits and of the
23right for the enrollee to elect to continue transitional care from the provider or facility
24under this subsection.
AB68-ASA2-AA2,76,2
12. Provide the enrollee an opportunity to notify the plan of the need for
2transitional care.
AB68-ASA2-AA2,76,93 3. Allow the enrollee to elect to continue to have the benefits provided under
4the plan under the same terms and conditions as would have applied to the item or
5service if the termination had not occurred for the course of treatment related to the
6enrollee's status as a continuing care patient beginning on the date on which the
7notice under subd. 1. is provided and ending 90 days after the date on which the
8notice under subd. 1. is provided or the date on which the enrollee is no longer a
9continuing care patient, whichever is earlier.
AB68-ASA2-AA2,76,13 10(9) Rule making. The commissioner may promulgate any rules necessary to
11implement this section, including specifying the independent dispute resolution
12process. The commissioner may promulgate rules to modify the list of those items
13and services for which a provider may not balance bill under sub. (5) (c).
AB68-ASA2-AA2,412c 14Section 412c. 609.713 of the statutes is created to read:
AB68-ASA2-AA2,76,16 15609.713 Essential health benefits; preventive services. Defined network
16plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
AB68-ASA2-AA2,412d 17Section 412d. 609.719 of the statutes is created to read:
AB68-ASA2-AA2,76,19 18609.719 Telehealth services. Limited service health organizations,
19preferred provider plans, and defined network plans are subject to s. 632.871.
AB68-ASA2-AA2,412e 20Section 412e. 609.83 of the statutes, as affected by 2021 Wisconsin Act 9, is
21amended to read:
AB68-ASA2-AA2,76,24 22609.83 Coverage of drugs and devices ; application of payments.
23Limited service health organizations, preferred provider plans, and defined network
24plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).
AB68-ASA2-AA2,412f
1Section 412f. 609.83 of the statutes, as affected by 2021 Wisconsin Act .... (this
2act), section 412e, is amended to read:
AB68-ASA2-AA2,77,6 3609.83 Coverage of drugs and devices; application of payments.
4Limited service health organizations, preferred provider plans, and defined network
5plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and
6(16v).
AB68-ASA2-AA2,412g 7Section 412g. 609.847 of the statutes is created to read:
AB68-ASA2-AA2,77,10 8609.847 Preexisting condition discrimination and certain benefit
9limits prohibited.
Limited service health organizations, preferred provider plans,
10and defined network plans are subject to s. 632.728.
AB68-ASA2-AA2,412h 11Section 412h. 625.12 (1) (a) of the statutes is amended to read:
AB68-ASA2-AA2,77,1312 625.12 (1) (a) Past and prospective loss and expense experience within and
13outside of this state, except as provided in s. 632.728.
AB68-ASA2-AA2,412i 14Section 412i. 625.12 (1) (e) of the statutes is amended to read:
AB68-ASA2-AA2,77,1615 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors,
16including the judgment of technical personnel.
AB68-ASA2-AA2,412j 17Section 412j. 625.12 (2) of the statutes is amended to read:
AB68-ASA2-AA2,78,218 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729,
19risks may be classified in any reasonable way for the establishment of rates and
20minimum premiums, except that no classifications may be based on race, color, creed
21or national origin, and classifications in automobile insurance may not be based on
22physical condition or developmental disability as defined in s. 51.01 (5). Subject to
23ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for
24individual risks in accordance with rating plans or schedules that establish

1reasonable standards for measuring probable variations in hazards, expenses, or
2both. Rates may also be modified for individual risks under s. 625.13 (2).
AB68-ASA2-AA2,412k 3Section 412k. 625.15 (1) of the statutes is amended to read:
AB68-ASA2-AA2,78,114 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
5itself establish rates and supplementary rate information for one or more market
6segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
7liability insurance, subject to s. 632.365, or the insurer may use rates and
8supplementary rate information prepared by a rate service organization, with
9average expense factors determined by the rate service organization or with such
10modification for its own expense and loss experience as the credibility of that
11experience allows.
AB68-ASA2-AA2,412L 12Section 412L. 628.34 (3) (a) of the statutes is amended to read:
AB68-ASA2-AA2,78,2013 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
14charging different premiums or by offering different terms of coverage except on the
15basis of classifications related to the nature and the degree of the risk covered or the
16expenses involved, subject to ss. 632.365, 632.729, 632.746 and, 632.748, and
17632.7496
. Rates are not unfairly discriminatory if they are averaged broadly among
18persons insured under a group, blanket or franchise policy, and terms are not
19unfairly discriminatory merely because they are more favorable than in a similar
20individual policy.
AB68-ASA2-AA2,412m 21Section 412m. 628.34 (3) (a) of the statutes, as affected by 2021 Wisconsin Act
22.... (this act), section 412L, is amended to read:
AB68-ASA2-AA2,79,523 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
24charging different premiums or by offering different terms of coverage except on the
25basis of classifications related to the nature and the degree of the risk covered or the

1expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746, 632.748, and
2632.7496. Rates are not unfairly discriminatory if they are averaged broadly among
3persons insured under a group, blanket or franchise policy, and terms are not
4unfairly discriminatory merely because they are more favorable than in a similar
5individual policy.
AB68-ASA2-AA2,412n 6Section 412n. 632.728 of the statutes is created to read:
AB68-ASA2-AA2,79,8 7632.728 Coverage of persons with preexisting conditions; guaranteed
8issue; benefit limits.
(1) Definitions. In this section:
AB68-ASA2-AA2,79,109 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar
10charges.
AB68-ASA2-AA2,79,1111 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).
AB68-ASA2-AA2,79,1212 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB68-ASA2-AA2,79,18 13(2) Guaranteed issue. (a) Every individual health benefit plan shall accept
14every individual in this state who, and every group health benefit plan shall accept
15every employer in this state that, applies for coverage, regardless of sexual
16orientation, gender identity, or whether or not any employee or individual has a
17preexisting condition. A health benefit plan may restrict enrollment in coverage
18described in this paragraph to open or special enrollment periods.
AB68-ASA2-AA2,79,2119 (b) The commissioner shall establish a statewide open enrollment period of no
20shorter than 30 days for every individual health benefit plan to allow individuals,
21including individuals who do not have coverage, to enroll in coverage.
AB68-ASA2-AA2,80,2 22(3) Prohibiting discrimination based on health status. (a) An individual
23health benefit plan or a self-insured health plan may not establish rules for the
24eligibility of any individual to enroll, or for the continued eligibility of any individual

1to remain enrolled, under the plan based on any of the following health
2status-related factors in relation to the individual or a dependent of the individual:
AB68-ASA2-AA2,80,33 1. Health status.
AB68-ASA2-AA2,80,44 2. Medical condition, including both physical and mental illnesses.
AB68-ASA2-AA2,80,55 3. Claims experience.
AB68-ASA2-AA2,80,66 4. Receipt of health care.
AB68-ASA2-AA2,80,77 5. Medical history.
AB68-ASA2-AA2,80,88 6. Genetic information.
AB68-ASA2-AA2,80,109 7. Evidence of insurability, including conditions arising out of acts of domestic
10violence.
AB68-ASA2-AA2,80,1111 8. Disability.
AB68-ASA2-AA2,80,1812 (b) An insurer offering an individual health benefit plan or a self-insured
13health plan may not require any individual, as a condition of enrollment or continued
14enrollment under the plan, to pay, on the basis of any health status-related factor
15under par. (a) with respect to the individual or a dependent of the individual, a
16premium or contribution or a deductible, copayment, or coinsurance amount that is
17greater than the premium or contribution or deductible, copayment, or coinsurance
18amount respectively for a similarly situated individual enrolled under the plan.
AB68-ASA2-AA2,80,2219 (c) Nothing in this subsection prevents an insurer offering an individual health
20benefit plan or a self-insured health plan from establishing premium discounts or
21rebates or modifying otherwise applicable cost sharing in return for adherence to
22programs of health promotion and disease prevention.
AB68-ASA2-AA2,80,25 23(4) Premium rate variation. A health benefit plan offered on the individual or
24small employer market or a self-insured health plan may vary premium rates for a
25specific plan based only on the following considerations:
AB68-ASA2-AA2,81,1
1(a) Whether the policy or plan covers an individual or a family.
AB68-ASA2-AA2,81,22 (b) Rating area in the state, as established by the commissioner.
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