Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,186,14 6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

SB45-SSA2-SA4,186,18 7. Ensure that essential health benefits established under this subsection are not subject to a coverage denial based on an insured’s or plan participant’s age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

SB45-SSA2-SA4,187,2 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

SB45-SSA2-SA4,187,7 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

SB45-SSA2-SA4,187,9 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

SB45-SSA2-SA4,187,14 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

SB45-SSA2-SA4,187,18 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.

SB45-SSA2-SA4,187,20 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

SB45-SSA2-SA4,265 Section 265. 632.895 (15m) of the statutes is created to read:

SB45-SSA2-SA4,187,22 632.895 (15m) Coverage of infertility services. (a) In this subsection:

SB45-SSA2-SA4,188,5 1. “Diagnosis of and treatment for infertility” means any recommended procedure or medication to treat infertility at the direction of a physician that is consistent with established, published, or approved medical practices or professional guidelines from the American College of Obstetricians and Gynecologists, or its successor organization, or the American Society for Reproductive Medicine, or its successor organization.

SB45-SSA2-SA4,188,7 2. “Infertility” means a disease, condition, or status characterized by any of the following:

SB45-SSA2-SA4,188,12 a. The failure to establish a pregnancy or carry a pregnancy to a live birth after regular, unprotected sexual intercourse for, if the woman is under the age of 35, no longer than 12 months or, if the woman is 35 years of age or older, no longer than 6 months, including any time during those 12 months or 6 months that the woman has a pregnancy that results in a miscarriage.

SB45-SSA2-SA4,188,14 b. An individual’s inability to reproduce either as a single individual or with a partner without medical intervention.

SB45-SSA2-SA4,188,16 c. A physician’s findings based on a patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.

SB45-SSA2-SA4,188,18 3. “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

SB45-SSA2-SA4,189,2 4. “Standard fertility preservation service” means a procedure that is consistent with established medical practices or professional guidelines published by the American Society for Reproductive Medicine, or its successor organization, or the American Society of Clinical Oncology, or its successor organization, for a person who has a medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.

SB45-SSA2-SA4,189,10 (b) Subject to pars. (c) to (e), every disability insurance policy and self-insured health plan that provides coverage for medical or hospital expenses shall cover diagnosis of and treatment for infertility and standard fertility preservation services. Coverage required under this paragraph includes at least 4 completed oocyte retrievals with unlimited embryo transfers, in accordance with the guidelines of the American Society for Reproductive Medicine, or its successor organization, and single embryo transfer when recommended and medically appropriate.

SB45-SSA2-SA4,189,12 (c) 1. A disability insurance policy or self-insured health plan may not do any of the following:

SB45-SSA2-SA4,189,15 a. Impose any exclusion, limitation, or other restriction on coverage required under par. (b) based on a covered individual’s participation in fertility services provided by or to a 3rd party.

SB45-SSA2-SA4,189,19 b. Impose any exclusion, limitation, or other restriction on coverage of medications that are required to be covered under par. (b) that are different from those imposed on any other prescription medications covered under the policy or plan.

SB45-SSA2-SA4,190,3 c. Impose any exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period, or other restriction on coverage that is required under par. (b) of diagnosis of and treatment for infertility and standard fertility preservation services that is different from an exclusion, limitation, cost-sharing requirement, benefit maximum, waiting period, or other restriction imposed on benefits for services that are covered by the policy or plan and that are not related to infertility.

SB45-SSA2-SA4,190,7 2. A disability insurance policy or self-insured health plan shall provide coverage required under par. (b) to any covered individual under the policy or plan, including any covered spouse or nonspouse dependent, to the same extent as other pregnancy-related benefits covered under the policy or plan.

SB45-SSA2-SA4,190,13 (d) The commissioner, after consulting with the department of health services on appropriate treatment for infertility, shall promulgate any rules necessary to implement this subsection. Before the promulgation of rules, disability insurance policies and self-insured health plans are considered to comply with the coverage requirements of par. (b) if the coverage conforms to the standards of the American Society for Reproductive Medicine.

SB45-SSA2-SA4,190,15 (e) This subsection does not apply to a disability insurance policy that is described under s. 632.745 (11) (b) 1. to 12.

SB45-SSA2-SA4,266 Section 266. 632.895 (16m) (b) of the statutes is amended to read:

SB45-SSA2-SA4,190,21 632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.

SB45-SSA2-SA4,267 Section 267. 632.895 (17) (b) 1m. of the statutes is created to read:

SB45-SSA2-SA4,191,2 632.895 (17) (b) 1m. Oral contraceptives that are lawfully furnished over the counter without a prescription.

SB45-SSA2-SA4,268 Section 268. 632.895 (17) (b) 2. of the statutes is amended to read:

SB45-SSA2-SA4,191,8 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.

SB45-SSA2-SA4,269 Section 269. 632.895 (17) (c) of the statutes is amended to read:

SB45-SSA2-SA4,192,2 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions, and limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan. A disability insurance policy or self-insured health plan may not apply a deductible or impose a copayment or coinsurance to at least one of each type of contraceptive method approved by the federal food and drug administration for which coverage is required under this subsection. The disability insurance policy or self-insured health plan may apply reasonable medical management to a method of contraception to limit coverage under this subsection that is provided without being subject to a deductible, copayment, or coinsurance to prescription drugs without a brand name. The disability insurance policy or self-insured health plan may apply a deductible or impose a copayment or coinsurance for coverage of a contraceptive that is prescribed for a medical need if the services for the medical need would otherwise be subject to a deductible, copayment, or coinsurance.

SB45-SSA2-SA4,270 Section 270. 632.897 (11) (a) of the statutes is amended to read:

SB45-SSA2-SA4,192,12 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t), 2011 stats.

SB45-SSA2-SA4,9123 Section 9123. Nonstatutory provisions; Insurance.

SB45-SSA2-SA4,192,16 (1) Prescription drug purchasing entity. During the 2025-27 fiscal biennium, the office of the commissioner of insurance shall conduct a study on the viability of creating or implementing a state prescription drug purchasing entity.

SB45-SSA2-SA4,192,23 (2) Staggered terms for prescription drug affordability review board. Notwithstanding the length of terms specified for the members of the prescription drug affordability review board under s. 15.735 (1) (b) to (e), 2 of the initial members shall be appointed for terms expiring on May 1, 2027; 2 of the initial members shall be appointed for terms expiring on May 1, 2028; 2 of the initial members shall be appointed for terms expiring on May 1, 2029; and 2 of the initial members shall be appointed for terms expiring on May 1, 2030.

SB45-SSA2-SA4,193,7 (3) Prescription drug importation program. The commissioner of insurance shall submit the first report required under s. 601.575 (5) by the next January 1 or July 1, whichever is earliest, that is at least 180 days after the date the prescription drug importation program is fully operational under s. 601.575 (4). The commissioner of insurance shall include in the first 3 reports submitted under s. 601.575 (5) information on the implementation of the audit functions under s. 601.575 (1) (n).

SB45-SSA2-SA4,193,11 (4) Public option health insurance plan. From the appropriation under s. 20.145 (1) (g), the office of the commissioner of insurance may expend not more than $500,000 in fiscal year 2025-26 and not more than $500,000 in fiscal year 2026-27 for the development of a public option health insurance plan.

SB45-SSA2-SA4,193,12 (5) Funding for health insurance navigators.

SB45-SSA2-SA4,193,13 (a) In this subsection:

SB45-SSA2-SA4,193,14 1. “Commissioner” means the commissioner of insurance.

SB45-SSA2-SA4,193,16 2. “Navigator” means an individual navigator licensed under s. 628.92 (1) or a navigator entity licensed under s. 628.92 (2).

SB45-SSA2-SA4,193,19 (b) From the appropriation under s. 20.145 (1) (g), the commissioner shall award $500,000 in fiscal year 2025-26 and shall award $500,000 in fiscal year 2026- 27 to a navigator to prioritize services for the direct care workforce population.

SB45-SSA2-SA4,9223 Section 9223. Fiscal changes; Insurance.

SB45-SSA2-SA4,194,2 (1) Health insurance risk-sharing plan balance transfer. Any balance of moneys that was credited to the appropriation account under s. 20.145 (5) (g), 2013 stats., or s. 20.145 (5) (k), 2013 stats., and that was not lapsed as a result of 2015 Wisconsin Act 55 is transferred in fiscal year 2025-26 to the appropriation account under s. 20.145 (1) (g).

SB45-SSA2-SA4,9323 Section 9323. Initial applicability; Insurance.

SB45-SSA2-SA4,194,4 (1) Coverage of infertility services.

SB45-SSA2-SA4,194,8 (a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in pars. (b) and (c).

SB45-SSA2-SA4,194,13 (b) For policies and plans that have a term greater than one year and contain provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) first applies to policy or plan years beginning on January 1 of the year following the year in which the policy or plan is extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,194,18 (c) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895 (15m) 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.

SB45-SSA2-SA4,194,20 (2) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services.

SB45-SSA2-SA4,195,4 (a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,195,13 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) 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.

SB45-SSA2-SA4,195,14 (3) Coverage of over-the-counter oral contraceptives.

SB45-SSA2-SA4,195,18 (a) For policies and plans containing provisions inconsistent with s. 632.895 (17) (b) 1m., the treatment of s. 632.895 (17) (b) 1m. first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,195,23 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with s. 632.895 (17) (b) 1m., the treatment of s. 632.895 (17) (b) 1m. 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,195,24 (4) Qualified treatment trainee coverage.

SB45-SSA2-SA4,196,6 (a) For policies and plans containing provisions inconsistent with ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, and 632.87 (7), the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, and 632.87 (7) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,196,13 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, and 632.87 (7), the treatment of ss. 40.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.713, and 632.87 (7) 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.

SB45-SSA2-SA4,196,14 (5) Dental therapist coverage.

SB45-SSA2-SA4,196,18 (a) For policies and plans containing provisions inconsistent with ss. 609.718 and 632.87 (1), (4), and (4e), the treatment of ss. 609.718 and 632.87 (1), (4), and (4e) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,196,24 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 609.718 and 632.87 (1), (4), and (4e), the treatment of ss. 609.718 and 632.87 (1), (4), and (4e) 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.

SB45-SSA2-SA4,197,1 (6) Application of manufacturer discounts.

SB45-SSA2-SA4,197,5 (a) For policies and plans containing provisions inconsistent with the treatment of s. 609.83, the treatment of s. 609.83 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,197,10 (b) For policies or plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of s. 609.83, the treatment of s. 609.83 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,197,11 (7) Application of manufacturer discounts.

SB45-SSA2-SA4,197,15 (a) For policies and plans containing provisions inconsistent with the treatment of s. 632.862, the treatment of s. 632.862 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,197,20 (b) For policies or plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of s. 632.862, the treatment of s. 632.862 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,197,21 (8) Substance abuse counselor coverage.

SB45-SSA2-SA4,198,2 (a) For policies and plans containing provisions inconsistent with the treatment of ss. 609.714 and 632.87 (8), the treatment of ss. 609.714 and 632.87 (8) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,198,8 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of ss. 609.714 and 632.87 (8), the treatment of ss. 609.714 and 632.87 (8) 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,198,9 (9) Telehealth parity.

SB45-SSA2-SA4,198,13 (a) For policies and plans containing provisions inconsistent with the treatment of s. 632.871, the treatment of s. 632.871 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,198,18 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of s. 632.871, the treatment of s. 632.871 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,198,19 (10) Coverage of emergency ambulance services.

SB45-SSA2-SA4,198,23 (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).

SB45-SSA2-SA4,199,5 (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.

SB45-SSA2-SA4,199,6 (11) Inpatient mental health prior authorization.

SB45-SSA2-SA4,199,10 (a) For policies and plans containing provisions inconsistent with ss. 609.823 and 632.891, the treatment of ss. 609.823 and 632.891 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,199,16 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 609.823 and 632.891, the treatment of ss. 609.823 and 632.891 first applies to policy or plan years beginning on the effective date of this subsection or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,199,17 (12) Special enrollment period for pregnancy.

SB45-SSA2-SA4,199,21 (a) For policies and plans containing provisions inconsistent with ss. 609.40 and 632.7498, the treatment of ss. 609.40 and 632.7498 first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

SB45-SSA2-SA4,200,3 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 609.40 and 632.7498, the treatment of ss. 609.40 and 632.7498 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 newly established, extended, modified, or renewed, whichever is later.

SB45-SSA2-SA4,9423 Section 9423. Effective dates; Insurance.

SB45-SSA2-SA4,200,7 (1) Coverage of infertility services. The treatment of ss. 609.74 and 632.895 (15m) and Section 9323 (1) of this act take effect on the first day of the 4th month beginning after publication.

SB45-SSA2-SA4,200,14 (2) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services. The treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) and Section 9323 (2) of this act take effect on the first day of the 4th month beginning after publication.

SB45-SSA2-SA4,200,17 (3) Coverage of over-the-counter oral contraceptives. The treatment of s. 632.895 (17) (b) 1m. and Section 9323 (3) of this act take effect on the first day of the 4th month beginning after publication.