SB45-SSA2-SA4,128,1313(7) Continuity of care. (a) In this subsection: SB45-SSA2-SA4,128,14141. “Continuing care patient” means an individual who is any of the following: SB45-SSA2-SA4,128,1615a. Undergoing a course of treatment for a serious and complex condition from 16a provider or facility. SB45-SSA2-SA4,128,1817b. Undergoing a course of institutional or inpatient care from a provider or 18facility. SB45-SSA2-SA4,128,2019c. Scheduled to undergo nonelective surgery, including receipt of postoperative 20care, from a provider or facility. SB45-SSA2-SA4,128,2221d. Pregnant and undergoing a course of treatment for the pregnancy from a 22provider or facility. SB45-SSA2-SA4,129,2
1e. Terminally ill and receiving treatment for the illness from a provider or 2facility. SB45-SSA2-SA4,129,332. “Serious and complex condition” means any of the following: SB45-SSA2-SA4,129,64a. In the case of an acute illness, a condition that is serious enough to require 5specialized medical treatment to avoid the reasonable possibility of death or 6permanent harm. SB45-SSA2-SA4,129,97b. In the case of a chronic illness or condition, a condition that is life-8threatening, degenerative, potentially disabling, or congenital and requires 9specialized medical care over a prolonged period. SB45-SSA2-SA4,129,1710(b) If an enrollee is a continuing care patient and is obtaining items or 11services from a participating provider or participating facility and the contract 12between the defined network plan, preferred provider plan, or self-insured 13governmental plan and the provider or facility is terminated because of a change in 14the terms of the participation of the provider or facility in the plan or the contract 15between the defined network plan, preferred provider plan, or self-insured 16governmental plan and the provider or facility is terminated, resulting in a loss of 17benefits provided under the plan, the plan shall do all of the following: SB45-SSA2-SA4,129,20181. Notify each enrollee of the termination of the contract or benefits and of the 19right for the enrollee to elect to continue transitional care from the participating 20provider or participating facility under this subsection. SB45-SSA2-SA4,129,22212. Provide the enrollee an opportunity to notify the plan of the need for 22transitional care. SB45-SSA2-SA4,130,6233. Allow the enrollee to elect to continue to have the benefits provided under
1the plan under the same terms and conditions as would have applied to the item or 2service if the termination had not occurred for the course of treatment related to the 3enrollee’s status as a continuing care patient beginning on the date on which the 4notice under subd. 1. is provided and ending 90 days after the date on which the 5notice under subd. 1. is provided or the date on which the enrollee is no longer a 6continuing care patient, whichever is earlier. SB45-SSA2-SA4,130,97(c) The provisions of s. 609.24 apply to a continuing care patient to the extent 8that s. 609.24 does not conflict with this subsection so as to limit the enrollee’s 9rights under this subsection. SB45-SSA2-SA4,130,1710(8) Rule making. The commissioner may promulgate any rules necessary to 11implement this section, including specifying the independent dispute resolution 12process under sub. (6). The commissioner may promulgate rules to modify the list 13of those items and services for which a provider may not bill or hold liable an 14enrollee under sub. (4) (c). In promulgating rules under this subsection, the 15commissioner may consider any rules promulgated by the federal department of 16health and human services pursuant to the federal No Surprises Act, 42 USC 17300gg-111, et seq. SB45-SSA2-SA4,131,219609.20 (3) The commissioner may promulgate rules to establish minimum 20network time and distance standards and minimum network wait-time standards 21for defined network plans and preferred provider plans. In promulgating rules 22under this subsection, the commissioner shall consider standards adopted by the 23federal centers for medicare and medicaid services for qualified health plans, as
1defined in 42 USC 18021 (a), that are offered through the federal health insurance 2exchange established pursuant to 42 USC 18041 (c). SB45-SSA2-SA4,131,74609.24 (5) Duration of benefits. If an enrollee is a continuing care patient, 5as defined in s. 609.04 (7) (a), and if any of the situations described under s. 609.04 6(7) (b) (intro.) applies, all of the following apply to the enrollee’s defined network 7plan: SB45-SSA2-SA4,131,108(a) Subsection (1) (c) shall apply to any of the participating providers 9providing the enrollee’s course of treatment under s. 609.04 (7), including the 10enrollee’s primary care physician. SB45-SSA2-SA4,131,1311(b) Subsection (1) (c) shall apply to lengthen the period in which benefits are 12provided under s. 609.04 (7) (b) 3. but may not be applied to shorten the period in 13which benefits are provided under s. 609.04 (7) (b) 3. SB45-SSA2-SA4,131,1514(c) Subsection (1) (d) may not be applied in a manner that limits the enrollee’s 15rights under s. 609.04 (7) (b) 3. SB45-SSA2-SA4,131,1816(d) No plan may contract or arrange with a participating provider to provide 17notice of the termination of the participating provider’s participation, pursuant to 18sub. (4). SB45-SSA2-SA4,131,2120609.40 Special enrollment period for pregnancy. Preferred provider 21plans and defined network plans are subject to s. 632.7498. SB45-SSA2-SA4,132,223609.712 Essential health benefits; preventive services. Defined
1network plans and preferred provider plans are subject to s. 632.895 (13m) and 2(14m). SB45-SSA2-SA4,132,64609.713 Qualified treatment trainee coverage. Limited service health 5organizations, preferred provider plans, and defined network plans are subject to s. 6632.87 (7). SB45-SSA2-SA4,132,108609.714 Substance abuse counselor coverage. Limited service health 9organizations, preferred provider plans, and defined network plans are subject to s. 10632.87 (8). SB45-SSA2-SA4,132,1312609.718 Dental therapist coverage. Limited service health organizations, 13preferred provider plans, and defined network plans are subject to s. 632.87 (4e). SB45-SSA2-SA4,132,1715609.719 Coverage for telehealth services. Limited service health 16organizations, preferred provider plans, and defined network plans are subject to s. 17632.871. SB45-SSA2-SA4,132,2019609.74 Coverage of infertility services. Defined network plans and 20preferred provider plans are subject to s. 632.895 (15m). SB45-SSA2-SA4,132,2422609.815 Exemption from prior authorization requirements. Limited 23service health organizations, preferred provider plans, and defined network plans 24are subject to any rules promulgated by the commissioner under s. 632.848. SB45-SSA2-SA4,133,42609.823 Coverage without prior authorization for inpatient mental 3health services. Limited service health organizations, preferred provider plans, 4and defined network plans are subject to s. 632.891. SB45-SSA2-SA4,133,76609.825 Coverage of emergency ambulance services. (1) In this 7section: SB45-SSA2-SA4,133,88(a) “Ambulance service provider” has the meaning given in s. 256.01 (3). SB45-SSA2-SA4,133,129(b) “Self-insured governmental plan” means a self-insured health plan of the 10state or a county, city, village, town, or school district that has a network of 11participating providers and imposes on enrollees in the self-insured health plan 12different requirements for using providers that are not participating providers. SB45-SSA2-SA4,133,1713(2) A defined network plan, preferred provider plan, or self-insured 14governmental plan that provides coverage of emergency medical services shall 15cover emergency ambulance services provided by an ambulance service provider 16that is not a participating provider at a rate that is not lower than the greatest rate 17that is any of the following: SB45-SSA2-SA4,133,1918(a) A rate that is set or approved by a local governmental entity in the 19jurisdiction in which the emergency ambulance services originated. SB45-SSA2-SA4,134,220(b) A rate that is 400 percent of the current published rate for the provided 21emergency ambulance services established by the federal centers for medicare and 22medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 23et seq., in the same geographic area or a rate that is equivalent to the rate billed by
1the ambulance service provider for emergency ambulance services provided, 2whichever is less. SB45-SSA2-SA4,134,53(c) The contracted rate at which the defined network plan, preferred provider 4plan, or self-insured governmental plan would reimburse a participating 5ambulance service provider for the same emergency ambulance services. SB45-SSA2-SA4,134,116(3) No defined network plan, preferred provider plan, or self-insured 7governmental plan may impose a cost-sharing amount on an enrollee for emergency 8ambulance services provided by an ambulance service provider that is not a 9participating provider at a rate that is greater than the requirements that would 10apply if the emergency ambulance services were provided by a participating 11ambulance service provider. SB45-SSA2-SA4,134,1512(4) No ambulance service provider that receives reimbursement under this 13section may bill an enrollee for any additional amount for emergency ambulance 14services except for any copayment, coinsurance, deductible, or other cost-sharing 15responsibilities required to be paid by the enrollee. SB45-SSA2-SA4,134,1716(5) For purposes of this section, “emergency ambulance services” does not 17include air ambulance services. SB45-SSA2-SA4,134,2219609.83 Coverage of drugs and devices; application of payments. 20Limited service health organizations, preferred provider plans, and defined 21network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), 22(16t), and (16v). SB45-SSA2-SA4,135,224609.847 Preexisting condition discrimination and certain benefit
1limits prohibited. Limited service health organizations, preferred provider 2plans, and defined network plans are subject to s. 632.728. SB45-SSA2-SA4,135,54625.12 (1) (a) Past and prospective loss and expense experience within and 5outside of this state, except as provided in s. 632.728. SB45-SSA2-SA4,135,87625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, 8including the judgment of technical personnel. SB45-SSA2-SA4,135,1810625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, 11risks may be classified in any reasonable way for the establishment of rates and 12minimum premiums, except that no classifications may be based on race, color, 13creed or national origin, and classifications in automobile insurance may not be 14based on physical condition or developmental disability as defined in s. 51.01 (5). 15Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified 16for individual risks in accordance with rating plans or schedules that establish 17reasonable standards for measuring probable variations in hazards, expenses, or 18both. Rates may also be modified for individual risks under s. 625.13 (2). SB45-SSA2-SA4,136,420625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may 21itself establish rates and supplementary rate information for one or more market 22segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 23liability insurance, subject to s. 632.365, or the insurer may use rates and
1supplementary rate information prepared by a rate service organization, with 2average expense factors determined by the rate service organization or with such 3modification for its own expense and loss experience as the credibility of that 4experience allows. SB45-SSA2-SA4,136,136628.34 (3) (a) No insurer may unfairly discriminate among policyholders by 7charging different premiums or by offering different terms of coverage except on the 8basis of classifications related to the nature and the degree of the risk covered or the 9expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, 10and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly 11among persons insured under a group, blanket or franchise policy, and terms are 12not unfairly discriminatory merely because they are more favorable than in a 13similar individual policy. SB45-SSA2-SA4,136,1615628.42 Disclosure and review of prior authorization requirements. 16(1) In this section: SB45-SSA2-SA4,136,1717(a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1. SB45-SSA2-SA4,136,2018(b) 1. “Prior authorization” means the process by which a health care plan or 19a contracted utilization review organization determines the medical necessity and 20medical appropriateness of otherwise covered health care services. SB45-SSA2-SA4,136,23212. “Prior authorization” includes any requirement that an enrollee or provider 22notify the health care plan or a contracted utilization review organization before, at 23the time of, or concurrent to providing a health care service. SB45-SSA2-SA4,136,2424(b) “Provider” has the meaning given in s. 628.36 (2) (a) 2. SB45-SSA2-SA4,137,3
1(2) (a) A health care plan shall maintain a complete list of services for which 2prior authorization is required, including services where prior authorization is 3performed by an entity under contract with the health care plan. SB45-SSA2-SA4,137,64(b) A health care plan shall publish the list under par. (a) on its website. The 5list shall be accessible by members of the general public without requiring the 6creation of any of an account or the entry of any credentials or personal information. SB45-SSA2-SA4,137,87(c) The list under par. (a) is not required to contain any clinical review criteria 8applicable to the services. SB45-SSA2-SA4,137,169(3) (a) A health care plan shall make any current prior authorization 10requirements and restrictions along with the clinical review criteria applicable to 11those requirements or restrictions accessible and conspicuously posted on its 12website to enrollees and providers. Content published by a 3rd party and licensed 13for use by a health care plan or a contracted utilization review organization may 14satisfy this subsection if it is available to access through the website of the health 15care plan or the contracted utilization review organization as long as the website 16does not unreasonably restrict access. SB45-SSA2-SA4,137,1917(b) The prior authorization requirements and restrictions under par. (a) shall 18be described in detail, and shall be written in easily understandable, plain 19language. SB45-SSA2-SA4,137,2220(c) The prior authorization requirements and restrictions under par. (a) shall 21indicate all of the following for each service subject to the prior authorization 22requirements and restrictions: SB45-SSA2-SA4,137,24231. When the requirement or restriction began for policies issued or delivered 24in this state, including effective dates and any termination dates. SB45-SSA2-SA4,138,2
12. The date that the requirement or restriction was listed on the website of the 2health care plan or a contracted utilization review organization. SB45-SSA2-SA4,138,333. The date that the requirement or restriction was removed in this state. SB45-SSA2-SA4,138,544. A method to access a standardized electronic prior authorization request 5transaction process. SB45-SSA2-SA4,138,76(4) Any clinical review criteria on which a prior authorization requirement or 7restriction is based shall satisfy all of the following: SB45-SSA2-SA4,138,98(a) The criteria are based on nationally recognized, generally accepted 9standards except where provided by law. SB45-SSA2-SA4,138,1110(b) The criteria are developed in accordance with the current standards of a 11national medical accreditation entity. SB45-SSA2-SA4,138,1312(c) The criteria ensure quality of care and access to needed health care 13services. SB45-SSA2-SA4,138,1414(d) The criteria are evidence-based. SB45-SSA2-SA4,138,1615(e) The criteria are sufficiently flexible to allow deviations from current 16standards when justified.
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