AB43: Bill Text

AB43,,8555 8. The enrollee provides consent to the nonparticipating provider to be treated by the nonparticipating provider, and the consent acknowledges that the enrollee has been informed that the charge paid by the enrollee may not meet a limitation that the enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan places on cost sharing, such as an in-network deductible.

AB43,,8556 9. A signed copy of the consent described under subd. 8. is provided to the enrollee.

AB43,,8557 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

AB43,,8558 1. If the enrollee makes an appointment for the item or service at least 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee at least 72 hours before the day of the appointment at which the item or service is to be provided.

AB43,,8559 2. If the enrollee makes an appointment for the item or service less than 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee on the day that the appointment is made.

AB43,,8560 (c) A provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for an ancillary item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service, whether or not provided by a physician or non-physician practitioner, unless the commissioner specifies by rule that the provider may balance bill for the ancillary item or service, if the item or service is any of the following:

AB43,,8561 1. Related to an emergency medical service.

AB43,,8562 2. Anesthesiology.

AB43,,8563 3. Pathology.

AB43,,8564 4. Radiology.

AB43,,8565 5. Neonatology.

AB43,,8566 6. An item or service provided by an assistant surgeon, hospitalist, or intensivist.

AB43,,8567 7. A diagnostic service, including a radiology or laboratory service.

AB43,,8568 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.

AB43,,8569 9. An item or service provided by a nonparticipating provider when there is no participating provider who can furnish the item or service at the participating facility.

AB43,,8570 (d) Any notice and consent provided under par. (a) may not extend to items or services furnished as a result of unforeseen, urgent medical needs that arise at the time the item or service is provided.

AB43,,8571 (e) Any consent provided under par. (a) shall be retained by the provider for no less than 7 years.

AB43,,8572 (5) Notice by provider or facility. Beginning no later than January 1, 2024, a health care provider or health care facility shall make available, including posting on a website, to enrollees in defined network plans, preferred provider plans, and self-insured governmental plans notice of the requirements on a provider or facility under sub. (4), of any other applicable state law requirements on the provider or facility with respect to charging an enrollee for an item or service if the provider or facility does not have a contractual relationship with the plan, and of information on contacting appropriate state or federal agencies in the event the enrollee believes the provider or facility violates any of the requirements under this section or other applicable law.

AB43,,8573 (6) Negotiation; dispute resolution. A provider or facility that is entitled to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may initiate, within 30 days of receiving the initial payment or notice of denial, open negotiations with the defined network plan, preferred provider plan, or self-insured governmental plan to determine a payment amount for an emergency medical service or other item or service for a period that terminates 30 days after initiating open negotiations. If the open negotiation period under this subsection terminates without determination of a payment amount, the provider, facility, defined network plan, preferred provider plan, or self-insured governmental plan may initiate, within the 4 days beginning on the day after the open negotiation period ends, the independent dispute resolution process as specified by the commissioner. If the independent dispute resolution decision-maker determines the payment amount, the party to the independent dispute resolution process whose amount was not selected shall pay the fees for the independent dispute resolution. If the parties to the independent dispute resolution reach a settlement on the payment amount, the parties to the independent dispute resolution shall equally divide the payment for the fees for the independent dispute resolution.

AB43,,8574 (7) Continuity of care. (a) In this subsection:

AB43,,8575 1. “Continuing care patient” means an individual who is any of the following:

AB43,,8576 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB43,,8577 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB43,,8578 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB43,,8579 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB43,,8580 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB43,,8581 2. “Serious and complex condition” means any of the following:

AB43,,8582 a. In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.

AB43,,8583 b. In the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized medical care over a prolonged period.

AB43,,8584 (b) If an enrollee is a continuing care patient and is obtaining items or services from a participating provider or participating facility and the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated, resulting in a loss of benefits provided under the plan, the plan shall do all of the following:

AB43,,8585 1. Notify each enrollee of the termination of the contract or benefits and of the right for the enrollee to elect to continue transitional care from the participating provider or participating facility under this subsection.

AB43,,8586 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB43,,8587 3. Allow the enrollee to elect to continue to have the benefits provided under the plan under the same terms and conditions as would have applied to the item or service if the termination had not occurred for the course of treatment related to the enrollee’s status as a continuing care patient beginning on the date on which the notice under subd. 1. is provided and ending 90 days after the date on which the notice under subd. 1. is provided or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.

AB43,,8588 (c) The provisions of s. 609.24 apply to a continuing care patient to the extent that s. 609.24 does not conflict with this subsection so as to limit the enrollee’s rights under this subsection.

AB43,,8589 (8) Rule making. The commissioner may promulgate any rules necessary to implement this section, including specifying the independent dispute resolution process under sub. (6). The commissioner may promulgate rules to modify the list of those items and services for which a provider may not balance bill under sub. (4) (c). In promulgating rules under this subsection, the commissioner may consider any rules promulgated by the federal department of health and human services pursuant to the federal No Suprises Act, 42 USC 300gg-111, et seq.

AB43,3051 Section 3051. 609.20 (3) of the statutes is created to read:

AB43,,8591 609.20 (3) The commissioner may promulgate rules to establish minimum network time and distance standards and minimum network wait-time standards for defined network plans and preferred provider plans. In promulgating rules under this subsection, the commissioner shall consider standards adopted by the federal centers for medicare and medicaid services for qualified health plans, as defined in 42 USC 18021 (a), that are offered through the federal health insurance exchange established pursuant to 42 USC 18041 (c).

AB43,3052 Section 3052. 609.24 (5) of the statutes is created to read:

AB43,,8593 609.24 (5) If an enrollee is a continuing care patient, as defined in s. 609.045 (7) (a), and if any of the situations described under s. 609.045 (7) (b) (intro.) applies, all of the following apply to the enrollee’s defined network plan:

AB43,,8594 (a) Subsection (1) (c) shall apply to any of the participating providers providing the enrollee’s course of treatment under s. 609.045 (7), including the enrollee’s primary care physician.

AB43,,8595 (b) Subsection (1) (c) shall apply to lengthen the period in which benefits are provided under s. 609.045 (7) (b) 3., but shall not be applied to shorten the period in which benefits are provided under s. 609.045 (7) (b) 3.

AB43,,8596 (c) Subsection (1) (d) shall not be applied in a manner that limits the enrollee’s rights under s. 609.045 (7) (b) 3.

AB43,,8597 (d) No plan may contract or arrange with a participating provider to provide notice of the termination of the participating provider’s participation, pursuant to sub. (4).

AB43,3053 Section 3053. 609.712 of the statutes is created to read:

AB43,,8599 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB43,3054 Section 3054. 609.713 of the statutes is created to read:

AB43,,8601 609.713 Qualified treatment trainee coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (7).

AB43,3055 Section 3055. 609.714 of the statutes is created to read:

AB43,,8603 609.714 Substance abuse counselor coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (8).

AB43,3056 Section 3056. 609.719 of the statutes is created to read:

AB43,,8605 609.719 Coverage for telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

AB43,3057 Section 3057. 609.74 of the statutes is created to read:

AB43,,8607 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

AB43,3058 Section 3058. 609.83 of the statutes is amended to read:

AB43,,8609 609.83 Coverage of drugs and devices; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and (16v).

****Note: This is reconciled s. 609.83. This Section has been affected by drafts with the following LRB numbers: -1152/P1 and -1157/P1.

AB43,3059 Section 3059. 609.847 of the statutes is created to read:

AB43,,8611 609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

AB43,3060 Section 3060. 611.11 (4) (a) of the statutes is amended to read:

AB43,,8613 611.11 (4) (a) In this subsection, “municipality” has the meaning given in s. 345.05 (1) (c), but also includes any transit authority created under s. 66.1039.

AB43,3061 Section 3061. 625.12 (1) (a) of the statutes is amended to read:

AB43,,8615 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

AB43,3062 Section 3062. 625.12 (1) (e) of the statutes is amended to read:

AB43,,8617 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

AB43,3063 Section 3063. 625.12 (2) of the statutes is amended to read:

AB43,,8619 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB43,3064 Section 3064. 625.15 (1) of the statutes is amended to read:

AB43,,8621 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB43,3065 Section 3065. 628.34 (3) (a) of the statutes is amended to read:

AB43,,8623 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

****Note: This is reconciled s. 628.34 (3) (a). This Section has been affected by drafts with the following LRB numbers: -1153/P1 and -1154/P1.

AB43,3066 Section 3066. 628.495 of the statutes is created to read:

AB43,,8625 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB43,,8626 (2) License required. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmacy benefit management broker or consultant or any other individual who procures the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

AB43,,8627 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

AB43,3067 Section 3067. 632.35 of the statutes is amended to read:

AB43,,8629 632.35 Prohibited rejection, cancellation and nonrenewal. No insurer may cancel or refuse to issue or renew an automobile insurance policy wholly or partially because of one or more of the following characteristics of any person: age, sex, residence, race, color, creed, religion, national origin, ancestry, marital status or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).

AB43,3068 Section 3068. 632.728 of the statutes is created to read:

AB43,,8631 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

AB43,,8632 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

AB43,,8633 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB43,,8634 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB43,,8635 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB43,,8636 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB43,,8637 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB43,,8638 1. Health status.

AB43,,8639 2. Medical condition, including both physical and mental illnesses.

AB43,,8640 3. Claims experience.

AB43,,8641 4. Receipt of health care.