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AB50-ASA2-AA8,3404Section 340. 66.0137 (4) of the statutes is amended to read:
AB50-ASA2-AA8,189,11566.0137 (4) Self-insured health plans. If a city, including a 1st class city,
6or a village provides health care benefits under its home rule power, or if a town
7provides health care benefits, to its officers and employees on a self-insured basis,
8the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
9632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85,
10632.851, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89,
11632.895 (9) to (17), 632.896, and 767.513 (4).
AB50-ASA2-AA8,34112Section 341. 120.13 (2) (g) of the statutes is amended to read:
AB50-ASA2-AA8,189,1613120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
1449.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and
15(b) 2., 632.747 (3), 632.798, 632.85, 632.851, 632.853, 632.855, 632.861, 632.867,
16632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
AB50-ASA2-AA8,34217Section 342. 185.983 (1) (intro.) of the statutes is amended to read:
AB50-ASA2-AA8,190,218185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
19cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
20646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
21601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
22631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795,
23632.798, 632.85, 632.851, 632.853, 632.855, 632.861, 632.867, 632.87 (2) to (6),

1632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609,
2620, 630, 635, 645, and 646, but the sponsoring association shall:
AB50-ASA2-AA8,3433Section 343. 609.825 of the statutes is created to read:
AB50-ASA2-AA8,190,54609.825 Coverage of emergency ambulance services. (1) In this
5section:
AB50-ASA2-AA8,190,66(a) Ambulance service provider has the meaning given in s. 256.01 (3).
AB50-ASA2-AA8,190,107(b) Self-insured governmental plan means a self-insured health plan of the
8state or a county, city, village, town, or school district that has a network of
9participating providers and imposes on enrollees in the self-insured health plan
10different requirements for using providers that are not participating providers.
AB50-ASA2-AA8,190,1511(2) A defined network plan, preferred provider plan, or self-insured
12governmental plan that provides coverage of emergency medical services shall
13cover emergency ambulance services provided by an ambulance service provider
14that is not a participating provider at a rate that is not lower than the greatest rate
15that is any of the following:
AB50-ASA2-AA8,190,1716(a) A rate that is set or approved by a local governmental entity in the
17jurisdiction in which the emergency ambulance services originated.
AB50-ASA2-AA8,190,2318(b) A rate that is 400 percent of the current published rate for the provided
19emergency ambulance services established by the federal centers for medicare and
20medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395
21et seq., in the same geographic area or a rate that is equivalent to the rate billed by
22the ambulance service provider for emergency ambulance services provided,
23whichever is less.
AB50-ASA2-AA8,191,3
1(c) The contracted rate at which the defined network plan, preferred provider
2plan, or self-insured governmental plan would reimburse a participating
3ambulance service provider for the same emergency ambulance services.
AB50-ASA2-AA8,191,94(3) No defined network plan, preferred provider plan, or self-insured
5governmental plan may impose a cost-sharing amount on an enrollee for emergency
6ambulance services provided by an ambulance service provider that is not a
7participating provider at a rate that is greater than the requirements that would
8apply if the emergency ambulance services were provided by a participating
9ambulance service provider.
AB50-ASA2-AA8,191,1310(4) No ambulance service provider that receives reimbursement under this
11section may bill an enrollee for any additional amount for emergency ambulance
12services except for any copayment, coinsurance, deductible, or other cost-sharing
13responsibilities required to be paid by the enrollee.
AB50-ASA2-AA8,191,1514(5) For purposes of this section, emergency ambulance services does not
15include air ambulance services.
AB50-ASA2-AA8,34416Section 344. 632.851 of the statutes is created to read:
AB50-ASA2-AA8,191,1817632.851 Reimbursement of emergency ambulance services. (1) In this
18section:
AB50-ASA2-AA8,191,1919(a) Ambulance service provider has the meaning given in s. 256.01 (3).
AB50-ASA2-AA8,191,2320(b) Clean claim means a claim that has no defect of impropriety, including a
21lack of required substantiating documentation or any particular circumstance that
22requires special treatment that prevents timely payment from being made on the
23claim.
AB50-ASA2-AA8,192,1
1(c) Emergency medical responder has the meaning given in s. 256.01 (4p).
AB50-ASA2-AA8,192,32(d) Emergency medical services practitioner has the meaning given in s.
3256.01 (5).
AB50-ASA2-AA8,192,44(e) Firefighter has the meaning given in s. 36.27 (3m) (a) 1m.
AB50-ASA2-AA8,192,55(f) Health care provider has the meaning given in s. 146.81 (1) (a) to (hp).
AB50-ASA2-AA8,192,66(g) Law enforcement officer has the meaning given in s. 165.85 (2) (c).
AB50-ASA2-AA8,192,77(h) Self-insured health plan has the meaning given in s. 632.85 (1) (c).
AB50-ASA2-AA8,192,138(2) (a) A disability insurance policy or self-insured health plan shall, within
930 days after receipt of a clean claim for covered emergency ambulance services,
10promptly remit payment for the covered emergency ambulance services directly to
11the ambulance service provider. No disability insurance policy or self-insured
12health plan may send a payment for covered emergency ambulance services to an
13enrollee.
AB50-ASA2-AA8,192,1814(b) A disability insurance policy or self-insured health plan shall respond to a
15claim for covered emergency ambulance services that is not a clean claim by sending
16a written notice, within 30 days after receipt of the claim, acknowledging the date of
17receipt of the claim and informing the ambulance service provider of one of the
18following:
AB50-ASA2-AA8,192,20191. That the disability insurance policy or self-insured health plan is declining
20to pay all or part of the claim, including the specific reason or reasons for the denial.
AB50-ASA2-AA8,192,22212. That additional information is necessary to determine if all or part of the
22claim is payable and the specific additional information that is required.
AB50-ASA2-AA8,193,423(3) A disability insurance policy or self-insured health plan shall remit

1payment for the transportation of any patient by ambulance as a medically
2necessary emergency ambulance service if the transportation was requested by an
3emergency medical services practitioner, an emergency medical responder, a
4firefighter, a law enforcement officer, or a health care provider.
AB50-ASA2-AA8,93235Section 9323. Initial applicability; Insurance.
AB50-ASA2-AA8,193,66(1) Coverage of emergency ambulance services.
AB50-ASA2-AA8,193,107(a) For policies and plans containing provisions inconsistent with ss. 609.825
8and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan
9years beginning on the effective date of this paragraph, except as provided in par.
10(b).
AB50-ASA2-AA8,193,1611(b) For policies and plans that are affected by a collective bargaining
12agreement containing provisions inconsistent with ss. 609.825 and 632.851, the
13treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning
14on the effective date of this paragraph or on the day on which the collective
15bargaining agreement is entered into, extended, modified, or renewed, whichever is
16later.
AB50-ASA2-AA8,942317Section 9423. Effective dates; Insurance.
AB50-ASA2-AA8,193,2118(1) Coverage of emergency ambulance services. The treatment of ss.
1940.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.825, and
20632.851 and Section 9323 (1) of this act take effect on the first day of the 4th month
21beginning after publication..
AB50-ASA2-AA8,193,222274. At the appropriate places, insert all of the following:
AB50-ASA2-AA8,193,2323Section 345. 601.45 (1) of the statutes is amended to read:
AB50-ASA2-AA8,194,824601.45 (1) Costs to be paid by examinees. The reasonable costs of

1examinations and audits under ss. 601.43, 601.44, 601.455, and 601.83 (5) (f) shall
2be paid by examinees except as provided in sub. (4), either on the basis of a system
3of billing for actual salaries and expenses of examiners and other apportionable
4expenses, including office overhead, or by a system of regular annual billings to
5cover the costs relating to a group of companies, or a combination of such systems,
6as the commissioner may by rule prescribe. Additional funding, if any, shall be
7governed by s. 601.32. The commissioner shall schedule annual hearings under s.
8601.41 (5) to review current problems in the area of examinations.
AB50-ASA2-AA8,3469Section 346. 601.455 of the statutes is created to read:
AB50-ASA2-AA8,194,1110601.455 Fair claims processing, health insurance transparency, and
11claim denial rate audits. (1) Definitions. In this section:
AB50-ASA2-AA8,194,1712(a) Claim denial means the refusal by an insurer to provide payment under
13a disability insurance policy for a service, treatment, or medication recommended
14by a health care provider. Claim denial includes the prospective refusal to pay for
15a service, treatment, or medication when a disability insurance policy requires
16advance approval before a prescribed medical service, treatment, or medication is
17provided.
AB50-ASA2-AA8,194,1818(b) Disability insurance policy has the meaning given in s. 632.895 (1) (a).
AB50-ASA2-AA8,194,1919(c) Health care provider has the meaning given in s. 146.81 (1) (a) to (p).
AB50-ASA2-AA8,194,2220(2) Claims processing. (a) Insurers shall process each claim for a disability
21insurance policy within a time frame that is reasonable and prevents an undue
22delay in an insureds care, taking into account the medical urgency of the claim.
AB50-ASA2-AA8,195,223(b) If an insurer determines additional information is needed to process a
24claim for a disability insurance policy, the insurer shall request the information

1from the insured within 5 business days of making the determination and shall
2provide at least 15 days for the insured to respond.
AB50-ASA2-AA8,195,33(c) All claim denials shall include all of the following:
AB50-ASA2-AA8,195,541. A specific and detailed explanation of the reason for the denial that cites
5the exact medical or policy basis for the denial.
AB50-ASA2-AA8,195,862. A copy of or a publicly accessible link to any policy, coverage rules, clinical
7guidelines, or medical evidence relied upon in making the denial decision, with
8specific citation to the provision justifying the denial.
AB50-ASA2-AA8,195,1193. Additional documentation, medical rationale, or criteria that must be met
10or provided for approval of the claim, including alternative options available under
11the policy.
AB50-ASA2-AA8,195,1412(d) If an insurer uses artificial intelligence or algorithmic decision-making in
13processing a claim for a disability insurance policy, the insurer must notify the
14insured in writing of that fact. The notice shall include all of the following:
AB50-ASA2-AA8,195,17151. A disclosure that artificial intelligence or algorithmic decision-making was
16used at any stage in reviewing the claim, even if a human later reviewed the
17outcome.
AB50-ASA2-AA8,195,20182. A detailed explanation of how the artificial intelligence or algorithmic
19decision-making reached its decision, including any factors the artificial
20intelligence or algorithmic decision-making weighed.
AB50-ASA2-AA8,195,22213. A contact point for requesting a human review of the claim if the claim was
22denied.
AB50-ASA2-AA8,196,223(3) Independent review of denials. In addition to an insureds right to an

1independent review under s. 632.835, as applicable, insureds have the right to
2request a review by the office of the public intervenor of any claim denial.
AB50-ASA2-AA8,196,43(4) Prohibited practices. An insurer may not do any of the following with
4respect to a disability insurance policy:
AB50-ASA2-AA8,196,55(a) Use vague or misleading policy terms to justify a claim denial.
AB50-ASA2-AA8,196,66(b) Fail to provide a specific and comprehensible reason for a claim denial.
AB50-ASA2-AA8,196,87(c) Cancel coverage under the policy after a claim is submitted due to alleged
8misstatements on the policy application.
AB50-ASA2-AA8,196,109(d) Deny a claim based on hidden or ambiguous exclusions in a disability
10insurance policy.
AB50-ASA2-AA8,196,1111(e) Stall review of a claim to avoid timely payment.
AB50-ASA2-AA8,196,1312(f) Reject a claim without reviewing all relevant medical records or consulting
13qualified experts.
AB50-ASA2-AA8,196,1514(g) Fail to properly review or respond to an insureds appeal in a timely
15manner.
AB50-ASA2-AA8,196,1716(h) Allow non-physician personnel to determine whether care is medically
17necessary.
AB50-ASA2-AA8,196,1918(i) Apply different medical necessity criteria based on financial interests
19rather than patient needs.
AB50-ASA2-AA8,196,2120(j) Disregard a treating health care providers medical assessment without a
21valid clinical reason.
AB50-ASA2-AA8,196,2322(k) Mandate prior approval for routine or urgent procedures in a manner that
23causes harmful delays.
AB50-ASA2-AA8,197,224(L) For a disability insurance policy that provides coverage of emergency

1medical services, refuse to cover emergency medical services provided by out-of-
2network providers.
AB50-ASA2-AA8,197,43(m) List a health care provider as in-network on a provider directory and then
4deny a claim by stating the health care provider is out-of-network.
AB50-ASA2-AA8,197,65(n) Deny coverage based on age, gender, disability, or a chronic condition
6rather than medical necessity.
AB50-ASA2-AA8,197,87(o) Apply stricter standards in reviewing claims related to mental health
8conditions than claims related to physical health conditions.
AB50-ASA2-AA8,197,109(p) Perform a blanket denial of claims for high-cost conditions without an
10individualized review of each claim.
AB50-ASA2-AA8,197,1111(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout.
AB50-ASA2-AA8,197,1312(s) Require an insured to fail a cheaper treatment before approving coverage
13for necessary care.
AB50-ASA2-AA8,197,1414(t) Manipulate cost-sharing rules to shift higher costs to insureds.
AB50-ASA2-AA8,197,1915(5) Transparency and reporting. (a) Beginning on January 1, 2027, an
16insurer shall annually publish a report detailing the insurers claim denial rates,
17reasons for claim denials, and the outcome of any appeal of a claim denial for the
18previous year for all disability insurance policies under which the insurer provides
19coverage.
AB50-ASA2-AA8,197,2120(b) The commissioner shall maintain a public database of insurers claim
21denial rates and the outcomes of independent reviews under s. 632.835.
AB50-ASA2-AA8,198,222(c) Beginning on January 1, 2027, an insurer that uses artificial intelligence
23or algorithmic decision-making in claims processing shall annually publish a report

1detailing all of the following for the previous year for all disability insurance policies
2under which the insurer provides coverage:
AB50-ASA2-AA8,198,431. The percentage of claims submitted to the insurer that were reviewed by
4artificial intelligence or algorithmic decision-making.
AB50-ASA2-AA8,198,752. The claim denial rate of claims reviewed by artificial intelligence or
6algorithmic decision-making compared to the claim denial rate of claims reviewed
7by humans.
AB50-ASA2-AA8,198,983. The steps the insurer takes to ensure fairness and accuracy in decisions
9made by artificial intelligence or algorithmic decision-making.
AB50-ASA2-AA8,198,1310(6) Claim denial rate audits. (a) The commissioner may conduct an audit
11of an insurer if the insurers claim denials are of such frequency as to indicate a
12general business practice. This paragraph is supplemental to and does not limit
13any other powers or duties of the commissioner.
AB50-ASA2-AA8,198,1514(b) The commissioner may collect any relevant information from an insurer
15that is necessary to conduct an audit under par. (a).
AB50-ASA2-AA8,198,1716(c) The commissioner may contract with a 3rd party to conduct an audit under
17par. (a).
AB50-ASA2-AA8,198,2218(d) The commissioner may, based on the findings of an audit under par. (a),
19order the insurer who is the subject of the audit to comply with a corrective action
20plan approved by the commissioner. The commissioner shall specify in any
21corrective action plan under this paragraph the deadline by which an insurer must
22be in compliance with the corrective action plan.
AB50-ASA2-AA8,198,2423(e) An insurer who is the subject of an audit under par. (a) shall provide a
24written response to any adverse findings of the audit.
AB50-ASA2-AA8,199,3
1(f) If an insurer fails to comply with a corrective action plan under par. (d) by
2the deadline specified by the commissioner, the commissioner may order the
3insurer to pay a forfeiture pursuant to s. 601.64 (3).
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