Amendment AA8-ASA2-AB50

AB50-ASA2-AA8,340 Section 340. 66.0137 (4) of the statutes is amended to read:

AB50-ASA2-AA8,189,11 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.851, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB50-ASA2-AA8,341 Section 341. 120.13 (2) (g) of the statutes is amended to read:

AB50-ASA2-AA8,189,16 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.851, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB50-ASA2-AA8,342 Section 342. 185.983 (1) (intro.) of the statutes is amended to read:

AB50-ASA2-AA8,190,2 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.851, 632.853, 632.855, 632.861, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

AB50-ASA2-AA8,343 Section 343. 609.825 of the statutes is created to read:

AB50-ASA2-AA8,190,5 609.825 Coverage of emergency ambulance services. (1) In this section:

AB50-ASA2-AA8,190,6 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

AB50-ASA2-AA8,190,10 (b) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

AB50-ASA2-AA8,190,15 (2) A defined network plan, preferred provider plan, or self-insured governmental plan that provides coverage of emergency medical services shall cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is not lower than the greatest rate that is any of the following:

AB50-ASA2-AA8,190,17 (a) A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.

AB50-ASA2-AA8,190,23 (b) 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 under title XVIII of the federal Social Security Act, 42 USC 1395 et seq., 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.

AB50-ASA2-AA8,191,3 (c) 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.

AB50-ASA2-AA8,191,9 (3) No defined network plan, preferred provider plan, or self-insured governmental plan may impose 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.

AB50-ASA2-AA8,191,13 (4) No ambulance service provider that receives reimbursement under this section may bill 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.

AB50-ASA2-AA8,191,15 (5) For purposes of this section, “emergency ambulance services” does not include air ambulance services.

AB50-ASA2-AA8,344 Section 344. 632.851 of the statutes is created to read:

AB50-ASA2-AA8,191,18 632.851 Reimbursement of emergency ambulance services. (1) In this section:

AB50-ASA2-AA8,191,19 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

AB50-ASA2-AA8,191,23 (b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.

AB50-ASA2-AA8,192,1 (c) “Emergency medical responder” has the meaning given in s. 256.01 (4p).

AB50-ASA2-AA8,192,3 (d) “Emergency medical services practitioner” has the meaning given in s. 256.01 (5).

AB50-ASA2-AA8,192,4 (e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m.

AB50-ASA2-AA8,192,5 (f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).

AB50-ASA2-AA8,192,6 (g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c).

AB50-ASA2-AA8,192,7 (h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA8,192,13 (2) (a) A disability insurance policy or self-insured health plan shall, within 30 days after receipt of a clean claim for covered emergency ambulance services, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. No disability insurance policy or self-insured health plan may send a payment for covered emergency ambulance services to an enrollee.

AB50-ASA2-AA8,192,18 (b) A disability insurance policy or self-insured health plan shall respond to a claim for covered emergency ambulance services that is not a clean claim by sending a written notice, within 30 days after receipt of the claim, acknowledging the date of receipt of the claim and informing the ambulance service provider of one of the following:

AB50-ASA2-AA8,192,20 1. That the disability insurance policy or self-insured health plan is declining to pay all or part of the claim, including the specific reason or reasons for the denial.

AB50-ASA2-AA8,192,22 2. That additional information is necessary to determine if all or part of the claim is payable and the specific additional information that is required.

AB50-ASA2-AA8,193,4 (3) A disability insurance policy or self-insured health plan shall remit payment for the transportation of any patient by ambulance as a medically necessary emergency ambulance service if the transportation was requested by an emergency medical services practitioner, an emergency medical responder, a firefighter, a law enforcement officer, or a health care provider.

AB50-ASA2-AA8,9323 Section 9323. Initial applicability; Insurance.

AB50-ASA2-AA8,193,6 (1) Coverage of emergency ambulance services.

AB50-ASA2-AA8,193,10 (a) For policies and plans containing provisions inconsistent with ss. 609.825 and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning on the effective date of this paragraph, except as provided in par. (b).

AB50-ASA2-AA8,193,16 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 609.825 and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is entered into, extended, modified, or renewed, whichever is later.

AB50-ASA2-AA8,9423 Section 9423. Effective dates; Insurance.

AB50-ASA2-AA8,193,21 (1) Coverage of emergency ambulance services. The treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.825, and 632.851 and Section 9323 (1) of this act take effect on the first day of the 4th month beginning after publication.”.

AB50-ASA2-AA8,193,22 74. At the appropriate places, insert all of the following:

AB50-ASA2-AA8,193,23 “Section 345. 601.45 (1) of the statutes is amended to read:

AB50-ASA2-AA8,194,8 601.45 (1) Costs to be paid by examinees. The reasonable costs of examinations and audits under ss. 601.43, 601.44, 601.455, and 601.83 (5) (f) shall be paid by examinees except as provided in sub. (4), either on the basis of a system of billing for actual salaries and expenses of examiners and other apportionable expenses, including office overhead, or by a system of regular annual billings to cover the costs relating to a group of companies, or a combination of such systems, as the commissioner may by rule prescribe. Additional funding, if any, shall be governed by s. 601.32. The commissioner shall schedule annual hearings under s. 601.41 (5) to review current problems in the area of examinations.

AB50-ASA2-AA8,346 Section 346. 601.455 of the statutes is created to read:

AB50-ASA2-AA8,194,11 601.455 Fair claims processing, health insurance transparency, and claim denial rate audits. (1) Definitions. In this section:

AB50-ASA2-AA8,194,17 (a) “Claim denial” means the refusal by an insurer to provide payment under a disability insurance policy for a service, treatment, or medication recommended by a health care provider. “Claim denial” includes the prospective refusal to pay for a service, treatment, or medication when a disability insurance policy requires advance approval before a prescribed medical service, treatment, or medication is provided.

AB50-ASA2-AA8,194,18 (b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB50-ASA2-AA8,194,19 (c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

AB50-ASA2-AA8,194,22 (2) Claims processing. (a) Insurers shall process each claim for a disability insurance policy within a time frame that is reasonable and prevents an undue delay in an insured’s care, taking into account the medical urgency of the claim.

AB50-ASA2-AA8,195,2 (b) If an insurer determines additional information is needed to process a claim for a disability insurance policy, the insurer shall request the information from the insured within 5 business days of making the determination and shall provide at least 15 days for the insured to respond.

AB50-ASA2-AA8,195,3 (c) All claim denials shall include all of the following:

AB50-ASA2-AA8,195,5 1. A specific and detailed explanation of the reason for the denial that cites the exact medical or policy basis for the denial.

AB50-ASA2-AA8,195,8 2. A copy of or a publicly accessible link to any policy, coverage rules, clinical guidelines, or medical evidence relied upon in making the denial decision, with specific citation to the provision justifying the denial.

AB50-ASA2-AA8,195,11 3. Additional documentation, medical rationale, or criteria that must be met or provided for approval of the claim, including alternative options available under the policy.

AB50-ASA2-AA8,195,14 (d) If an insurer uses artificial intelligence or algorithmic decision-making in processing a claim for a disability insurance policy, the insurer must notify the insured in writing of that fact. The notice shall include all of the following:

AB50-ASA2-AA8,195,17 1. A disclosure that artificial intelligence or algorithmic decision-making was used at any stage in reviewing the claim, even if a human later reviewed the outcome.

AB50-ASA2-AA8,195,20 2. A detailed explanation of how the artificial intelligence or algorithmic decision-making reached its decision, including any factors the artificial intelligence or algorithmic decision-making weighed.

AB50-ASA2-AA8,195,22 3. A contact point for requesting a human review of the claim if the claim was denied.

AB50-ASA2-AA8,196,2 (3) Independent review of denials. In addition to an insured’s right to an independent review under s. 632.835, as applicable, insureds have the right to request a review by the office of the public intervenor of any claim denial.

AB50-ASA2-AA8,196,4 (4) Prohibited practices. An insurer may not do any of the following with respect to a disability insurance policy:

AB50-ASA2-AA8,196,5 (a) Use vague or misleading policy terms to justify a claim denial.

AB50-ASA2-AA8,196,6 (b) Fail to provide a specific and comprehensible reason for a claim denial.

AB50-ASA2-AA8,196,8 (c) Cancel coverage under the policy after a claim is submitted due to alleged misstatements on the policy application.

AB50-ASA2-AA8,196,10 (d) Deny a claim based on hidden or ambiguous exclusions in a disability insurance policy.

AB50-ASA2-AA8,196,11 (e) Stall review of a claim to avoid timely payment.

AB50-ASA2-AA8,196,13 (f) Reject a claim without reviewing all relevant medical records or consulting qualified experts.

AB50-ASA2-AA8,196,15 (g) Fail to properly review or respond to an insured’s appeal in a timely manner.

AB50-ASA2-AA8,196,17 (h) Allow non-physician personnel to determine whether care is medically necessary.

AB50-ASA2-AA8,196,19 (i) Apply different medical necessity criteria based on financial interests rather than patient needs.

AB50-ASA2-AA8,196,21 (j) Disregard a treating health care provider’s medical assessment without a valid clinical reason.

AB50-ASA2-AA8,196,23 (k) Mandate prior approval for routine or urgent procedures in a manner that causes harmful delays.

AB50-ASA2-AA8,197,2 (L) For a disability insurance policy that provides coverage of emergency medical services, refuse to cover emergency medical services provided by out-of- network providers.

AB50-ASA2-AA8,197,4 (m) List a health care provider as in-network on a provider directory and then deny a claim by stating the health care provider is out-of-network.

AB50-ASA2-AA8,197,6 (n) Deny coverage based on age, gender, disability, or a chronic condition rather than medical necessity.

AB50-ASA2-AA8,197,8 (o) Apply stricter standards in reviewing claims related to mental health conditions than claims related to physical health conditions.

AB50-ASA2-AA8,197,10 (p) Perform a blanket denial of claims for high-cost conditions without an individualized review of each claim.

AB50-ASA2-AA8,197,11 (r) Reclassify a claim to a lower-cost treatment to reduce insurer payout.

AB50-ASA2-AA8,197,13 (s) Require an insured to fail a cheaper treatment before approving coverage for necessary care.

AB50-ASA2-AA8,197,14 (t) Manipulate cost-sharing rules to shift higher costs to insureds.

AB50-ASA2-AA8,197,19 (5) Transparency and reporting. (a) Beginning on January 1, 2027, an insurer shall annually publish a report detailing the insurer’s claim denial rates, reasons for claim denials, and the outcome of any appeal of a claim denial for the previous year for all disability insurance policies under which the insurer provides coverage.

AB50-ASA2-AA8,197,21 (b) The commissioner shall maintain a public database of insurers’ claim denial rates and the outcomes of independent reviews under s. 632.835.

AB50-ASA2-AA8,198,2 (c) Beginning on January 1, 2027, an insurer that uses artificial intelligence or algorithmic decision-making in claims processing shall annually publish a report detailing all of the following for the previous year for all disability insurance policies under which the insurer provides coverage:

AB50-ASA2-AA8,198,4 1. The percentage of claims submitted to the insurer that were reviewed by artificial intelligence or algorithmic decision-making.

AB50-ASA2-AA8,198,7 2. The claim denial rate of claims reviewed by artificial intelligence or algorithmic decision-making compared to the claim denial rate of claims reviewed by humans.

AB50-ASA2-AA8,198,9 3. The steps the insurer takes to ensure fairness and accuracy in decisions made by artificial intelligence or algorithmic decision-making.

AB50-ASA2-AA8,198,13 (6) Claim denial rate audits. (a) The commissioner may conduct an audit of an insurer if the insurer’s claim denials are of such frequency as to indicate a general business practice. This paragraph is supplemental to and does not limit any other powers or duties of the commissioner.

AB50-ASA2-AA8,198,15 (b) The commissioner may collect any relevant information from an insurer that is necessary to conduct an audit under par. (a).

AB50-ASA2-AA8,198,17 (c) The commissioner may contract with a 3rd party to conduct an audit under par. (a).

AB50-ASA2-AA8,198,22 (d) The commissioner may, based on the findings of an audit under par. (a), order the insurer who is the subject of the audit to comply with a corrective action plan approved by the commissioner. The commissioner shall specify in any corrective action plan under this paragraph the deadline by which an insurer must be in compliance with the corrective action plan.

AB50-ASA2-AA8,198,24 (e) An insurer who is the subject of an audit under par. (a) shall provide a written response to any adverse findings of the audit.

AB50-ASA2-AA8,199,3 (f) If an insurer fails to comply with a corrective action plan under par. (d) by the deadline specified by the commissioner, the commissioner may order the insurer to pay a forfeiture pursuant to s. 601.64 (3).