December 8, 2023 - Introduced by Representatives J. Anderson, Clancy, Considine, Drake, Emerson, Jacobson, Joers, Madison, Moore Omokunde, Ortiz-Velez, Ratcliff, Shankland, Shelton and Snodgrass, cosponsored by Senators Larson, Carpenter and Spreitzer. Referred to Committee on Insurance.
AB792,,22An Act to create 609.048 of the statutes; relating to: evaluation of health plan network sufficiency. AB792,,33Analysis by the Legislative Reference Bureau This bill requires the commissioner of insurance to determine the sufficiency of the network of providers of a defined network plan or preferred provider plan to ensure that all covered services are accessible to enrollees without unreasonable travel or delay. Defined network plans and preferred provider plans are types of managed care organizations that provide health care benefits to their enrollees. The bill authorizes the commissioner to require a plan to make accommodations for enrollees to obtain covered services if the plan’s network is insufficient. The bill also specifies factors that the commissioner may consider when determining whether a plan’s network is sufficient.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
AB792,,44The people of the state of Wisconsin, represented in senate and assembly, do enact as follows: AB792,15Section 1. 609.048 of the statutes is created to read: AB792,,66609.048 Network sufficiency. The commissioner shall determine the sufficiency of a defined network plan’s or preferred provider plan’s network to ensure that all covered services are accessible to enrollees without unreasonable travel or delay. The commissioner may require a defined network plan or preferred provider plan to make accommodations for enrollees to obtain covered services if its network is insufficient. Factors the commissioner may consider when determining network sufficiency include any of the following: AB792,,77(1) The ratio of primary providers to enrollees. AB792,,88(2) The geographic accessibility of providers. AB792,,99(3) The waiting time for an appointment with a provider of a particular specialty in the network. AB792,,1010(4) The ability of the network to meet the needs of the population of enrollees. AB792,,1111(5) The extent to which providers in the network are accepting new patients. AB792,,1212(6) Whether the plan has a process of ensuring that enrollees are able to obtain a covered service at an out-of-pocket cost that is equivalent to the cost of a service provided by a provider in the network if a provider in the network is not available to provide the covered service without unreasonable travel or delay.
