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SB45-SSA2-SA4,126,14141. Related to an emergency medical service.
SB45-SSA2-SA4,126,15152. Anesthesiology.
SB45-SSA2-SA4,126,16163. Pathology.
SB45-SSA2-SA4,126,17174. Radiology.
SB45-SSA2-SA4,126,18185. Neonatology.
SB45-SSA2-SA4,126,20196. An item or service provided by an assistant surgeon, hospitalist, or
20intensivist.
SB45-SSA2-SA4,126,21217. A diagnostic service, including a radiology or laboratory service.
SB45-SSA2-SA4,126,23228. An item or service provided by a specialty practitioner that the
23commissioner specifies by rule.
SB45-SSA2-SA4,127,3
19. An item or service provided by a nonparticipating provider when there is no
2participating provider who can furnish the item or service at the participating
3facility.
SB45-SSA2-SA4,127,64(d) Any notice and consent provided under par. (a) may not extend to items or
5services furnished as a result of unforeseen, urgent medical needs that arise at the
6time the item or service is provided.
SB45-SSA2-SA4,127,87(e) Any consent provided under par. (a) shall be retained by the provider for no
8less than 7 years.
SB45-SSA2-SA4,127,189(5) Notice by provider or facility. Beginning no later than January 1,
102026, a health care provider or health care facility shall make available, including
11posting on a website, to enrollees in defined network plans, preferred provider
12plans, and self-insured governmental plans notice of the requirements on a provider
13or facility under sub. (4), of any other applicable state law requirements on the
14provider or facility with respect to charging an enrollee for an item or service if the
15provider or facility does not have a contractual relationship with the plan, and of
16information on contacting appropriate state or federal agencies in the event the
17enrollee believes the provider or facility violates any of the requirements under this
18section or other applicable law.
SB45-SSA2-SA4,128,1219(6) Negotiation; dispute resolution. A provider or facility that is entitled
20to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may
21initiate, within 30 days of receiving the initial payment or notice of denial, open
22negotiations with the defined network plan, preferred provider plan, or self-insured
23governmental plan to determine a payment amount for an emergency medical

1service or other item or service for a period that terminates 30 days after initiating
2open negotiations. If the open negotiation period under this subsection terminates
3without determination of a payment amount, the provider, facility, defined network
4plan, preferred provider plan, or self-insured governmental plan may initiate,
5within the 4 days beginning on the day after the open negotiation period ends, the
6independent dispute resolution process as specified by the commissioner. If the
7independent dispute resolution decision-maker determines the payment amount,
8the party to the independent dispute resolution process whose amount was not
9selected shall pay the fees for the independent dispute resolution. If the parties to
10the independent dispute resolution reach a settlement on the payment amount, the
11parties to the independent dispute resolution shall equally divide the payment for
12the fees for the independent dispute resolution.
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
3enrollees 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 enrollees
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-SA4,19918Section 199. 609.20 (3) of the statutes is created to read:
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-SA4,2003Section 200. 609.24 (5) of the statutes is created to read:
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 enrollees defined network
7plan:
SB45-SSA2-SA4,131,108(a) Subsection (1) (c) shall apply to any of the participating providers
9providing the enrollees course of treatment under s. 609.04 (7), including the
10enrollees 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 enrollees
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 providers participation, pursuant to
18sub. (4).
SB45-SSA2-SA4,20119Section 201. 609.40 of the statutes is created to read:
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-SA4,20222Section 202. 609.712 of the statutes is created to read:
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-SA4,2033Section 203. 609.713 of the statutes is created to read:
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-SA4,2047Section 204. 609.714 of the statutes is created to read:
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-SA4,20511Section 205. 609.718 of the statutes is created to read:
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-SA4,20614Section 206. 609.719 of the statutes is created to read:
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-SA4,20718Section 207. 609.74 of the statutes is created to read:
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-SA4,20821Section 208. 609.815 of the statutes is created to read:
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-SA4,209
1Section 209. 609.823 of the statutes is created to read:
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-SA4,2105Section 210. 609.825 of the statutes is created to read:
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-SA4,21118Section 211. 609.83 of the statutes is amended to read:
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-SA4,21223Section 212. 609.847 of the statutes is created to read:
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-SA4,2133Section 213. 625.12 (1) (a) of the statutes is amended to read:
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-SA4,2146Section 214. 625.12 (1) (e) of the statutes is amended to read:
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-SA4,2159Section 215. 625.12 (2) of the statutes is amended to read:
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-SA4,21619Section 216. 625.15 (1) of the statutes is amended to read:
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-SA4,2175Section 217. 628.34 (3) (a) of the statutes is amended to read:
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-SA4,21814Section 218. 628.42 of the statutes is created to read:
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.
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