SB645: Bill Text

SB645,,2 An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g) and 185.983 (1) (intro.); and to create 609.843 and 632.895 (18) of the statutes; relating to: coverage of routine care related to certain clinical trials by health insurance policies and plans.

SB645,,3 Analysis by the Legislative Reference Bureau

This bill makes several changes with respect to coverage of routine patient costs and items or services by health insurance policies and plans furnished in connection with participation in an approved clinical trial. The bill requires health insurance policies that provide coverage for hospital care to provide coverage for routine patient costs and items or services furnished in connection with participation by a qualified individual in an approved clinical trial. “Qualified individual” is defined under the bill to mean an individual who is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening condition. The bill prohibits health insurance policies from discriminating against any individual based on the individual’s participation in an approved clinical trial. Health insurance policies are referred to in the bill as disability insurance policies.

Further, the bill requires limited service health organizations, preferred provider plans, and defined network plans that provide coverage of routine patient costs and items or services furnished in connection with participation by a qualified individual in an approved clinical trial to impose the same cost-sharing requirements to such item or service when provided by a nonparticipating provider that would apply if such item or service were furnished by a participating provider and pay to the nonparticipating provider the amount by which the recognized amount for such item or service exceeds the cost-sharing amount for such item or service.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

SB645,,4 The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB645,1 Section 1. 40.51 (8) of the statutes is amended to read:

SB645,,6 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 609.843, 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.

SB645,2 Section 2. 40.51 (8m) of the statutes is amended to read:

SB645,,8 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 609.843, 631.95, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861, 632.867, 632.885, 632.89, and 632.895 (11) to (17).

SB645,3 Section 3. 66.0137 (4) of the statutes is amended to read:

SB645,,10 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 609.843, 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB645,4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

SB645,,12 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 609.843, 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB645,5 Section 5. 185.983 (1) (intro.) of the statutes is amended to read:

SB645,,14 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 609.843, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

SB645,6 Section 6. 609.843 of the statutes is created to read:

SB645,,16 609.843 Coverage of routine care related to clinical trials. (1) In this section:

SB645,,17 (a) “Approved clinical trial” has the meaning given in 42 USC 300gg-8 (d).

SB645,,18 (b) “Life-threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

SB645,,19 (c) “Qualified individual” means an individual who is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening condition.

SB645,,20 (d) “Recognized amount” has the meaning given by the commissioner by rule or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).

SB645,,21 (e) “Routine patient costs” has the meaning given in 42 USC 300gg-8 (a) (2).

SB645,,22 (2) Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.895 (18).

SB645,,23 (3) A limited service health organization, preferred provider plan, or defined network plan that provides coverage of routine patient costs and items or services furnished in connection with participation by a qualified individual in an approved clinical trial shall do all of the following with respect to routine patient costs and items or services furnished in connection with participation by a qualified individual in an approved clinical trial by a nonparticipating provider:

SB645,,24 (a) Impose the same cost-sharing requirements that would apply if such item or service were furnished by a participating provider.

SB645,,25 (b) Pay to such nonparticipating provider the amount by which the recognized amount for such item or service exceeds the cost-sharing amount for such item or service.

SB645,7 Section 7. 632.895 (18) of the statutes is created to read:

SB645,,27 632.895 (18) Coverage of routine costs for clinical trials. (a) In this subsection:

SB645,,28 1. “Approved clinical trial” has the meaning given in 42 USC 300gg-8 (d).

SB645,,29 2. “Life-threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

SB645,,30 3. “Qualified individual” means an individual who is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening condition.

SB645,,31 4. “Routine patient costs” has the meaning given in 42 USC 300gg-8 (a) (2).

SB645,,32 (b) Each disability insurance policy that provides coverage for hospital care shall provide coverage for routine patient costs and items or services furnished in connection with participation by a qualified individual in an approved clinical trial.

SB645,,33 (c) No disability insurance policy may discriminate against an individual on the basis of the individual’s participation in an approved clinical trial.

SB645,8 Section 8. Initial applicability.

SB645,,35 (1) For policies and plans containing provisions inconsistent with this act, the act first applies to policy or plan years beginning on January 1 of the year following the year in which this subsection takes effect, except as provided in sub. (2).

SB645,,36 (2) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with this act, this act 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.

SB645,9 Section 9. Effective date.

SB645,,38 (1) This act takes effect on the first day of the 4th month beginning after publication.

SB645,,39 (end)