AB50,1411,1815(d) A generic drug that has a wholesale acquisition cost, as adjusted annually 16to reflect adjustments to the U.S. consumer price index for all urban consumers, 17U.S. city average, as determined by the U.S. department of labor, that meets all of 18the following conditions: AB50,1412,2191. Is at least $100 for a supply lasting a patient for a period of 30 consecutive 20days based on the recommended dosage approved for labeling by the federal food 21and drug administration, a supply lasting a patient for a period of fewer than 30 22days based on the recommended dosage approved for labeling by the federal food
1and drug administration, or one unit of the drug if the labeling approved by the 2federal food and drug administration does not recommend a finite dosage. AB50,1412,632. Increased by at least 200 percent during the preceding 12-month period, as 4determined by the difference between the resulting wholesale acquisition cost and 5the average of the wholesale acquisition cost reported over the preceding 12 6months. AB50,1412,97(e) Other prescription drug products, including drugs to address public health 8emergencies, that may create affordability challenges for the health care system 9and patients in this state. AB50,1412,1410(2) Affordability review. (a) After identifying prescription drug products 11under sub. (1), the board shall determine whether to conduct an affordability 12review for each identified prescription drug product by seeking stakeholder input 13about the prescription drug product and considering the average patient cost share 14of the prescription drug product. AB50,1412,2015(b) The information used to conduct an affordability review under par. (a) may 16include any document and research related to the manufacturer’s selection of the 17introductory price or price increase of the prescription drug product, including life 18cycle management, net average price in this state, market competition and context, 19projected revenue, and the estimated value or cost-effectiveness of the prescription 20drug product. AB50,1412,2321(c) The failure of a manufacturer to provide the board with information for an 22affordability review under par. (b) does not affect the authority of the board to 23conduct the review. AB50,1413,8
1(3) Affordability challenge. When conducting an affordability review of a 2prescription drug product under sub. (2), the board shall determine whether use of 3the prescription drug product that is fully consistent with the labeling approved by 4the federal food and drug administration or standard medical practice has led or 5will lead to an affordability challenge for the health care system in this state, 6including high out-of-pocket costs for patients. To the extent practicable, in 7determining whether a prescription drug product has led or will lead to an 8affordability challenge, the board shall consider all of the following factors: AB50,1413,109(a) The wholesale acquisition cost for the prescription drug product sold in 10this state. AB50,1413,1411(b) The average monetary price concession, discount, or rebate the 12manufacturer provides, or is expected to provide, to health plans in this state as 13reported by manufacturers and health plans, expressed as a percentage of the 14wholesale acquisition cost for the prescription drug product under review. AB50,1413,1815(c) The total amount of the price concessions, discounts, and rebates the 16manufacturer provides to each pharmacy benefit manager for the prescription drug 17product under review, as reported by the manufacturer and pharmacy benefit 18manager and expressed as a percentage of the wholesale acquisition cost. AB50,1413,2019(d) The price at which therapeutic alternatives to the prescription drug 20product have been sold in this state. AB50,1413,2321(e) The average monetary concession, discount, or rebate the manufacturer 22provides or is expected to provide to health plan payors and pharmacy benefit 23managers in this state for therapeutic alternatives to the prescription drug product. AB50,1414,3
1(f) The costs to health plans based on patient access consistent with labeled 2indications by the federal food and drug administration and recognized standard 3medical practice. AB50,1414,54(g) The impact on patient access resulting from the cost of the prescription 5drug product relative to insurance benefit design. AB50,1414,76(h) The current or expected dollar value of drug-specific patient access 7programs that are supported by the manufacturer. AB50,1414,108(i) The relative financial impacts to health, medical, or social services costs 9that can be quantified and compared to baseline effects of existing therapeutic 10alternatives to the prescription drug product. AB50,1414,1211(j) The average patient copay or other cost sharing for the prescription drug 12product in this state. AB50,1414,1313(k) Any information a manufacturer chooses to provide. AB50,1414,1414(L) Any other factors as determined by the board by rule. AB50,1414,1815(4) Upper payment limit. (a) If the board determines under sub. (3) that use 16of a prescription drug product has led or will lead to an affordability challenge, the 17board shall establish an upper payment limit for the prescription drug product after 18considering all of the following: AB50,1414,19191. The cost of administering the drug. AB50,1414,20202. The cost of delivering the drug to consumers. AB50,1414,21213. Other relevant administrative costs related to the drug. AB50,1415,422(b) For a prescription drug product identified in sub. (1) (b) or (d) 2., the board 23shall solicit information from the manufacturer regarding the price increase. To
1the extent that the price increase is not a result of the need for increased 2manufacturing capacity or other effort to improve patient access during a public 3health emergency, the board shall establish an upper payment limit under par. (a) 4that is equal to the cost to consumers prior to the price increase. AB50,1415,85(c) 1. The upper payment limit established under this subsection shall apply 6to all purchases and payor reimbursements of the prescription drug product 7dispensed or administered to individuals in this state in person, by mail, or by other 8means. AB50,1415,1992. Notwithstanding subd. 1., while state-sponsored and state-regulated 10health plans and health programs shall limit drug reimbursements and drug 11payment to no more than the upper payment limit established under this 12subsection, a plan subject to the Employee Retirement Income Security Act of 1974 13or Part D of Medicare under 42 USC 1395w-101 et seq. may choose to reimburse 14more than the upper payment limit. A provider who dispenses and administers a 15prescription drug product in this state to an individual in this state may not bill a 16payor more than the upper payment limit to the patient regardless of whether a 17plan subject to the Employee Retirement Income Security Act of 1974 or Part D of 18Medicare under 42 USC 1395w-101 et seq. chooses to reimburse the provider above 19the upper payment limit. AB50,1415,2120(5) Public inspection. Information submitted to the board under this 21section shall be open to public inspection only as provided under ss. 19.31 to 19.39. AB50,1416,222(6) No prohibition on marketing. Nothing in this section may be construed 23to prevent a manufacturer from marketing a prescription drug product approved by
1the federal food and drug administration while the prescription drug product is 2under review by the board. AB50,1416,73(7) Appeals. A person aggrieved by a decision of the board may request an 4appeal of the decision no later than 30 days after the board makes the 5determination. The board shall hear the appeal and make a final decision no later 6than 60 days after the appeal is requested. A person aggrieved by a final decision of 7the board may petition for judicial review in a court of competent jurisdiction. AB50,28948Section 2894. 601.83 (1) (a) of the statutes is amended to read: AB50,1416,219601.83 (1) (a) The commissioner shall administer a state-based reinsurance 10program known as the healthcare stability plan in accordance with the specific 11terms and conditions approved by the federal department of health and human 12services dated July 29, 2018. Before December 31, 2023, the commissioner may not 13request from the federal department of health and human services a modification, 14suspension, withdrawal, or termination of the waiver under 42 USC 18052 under 15which the healthcare stability plan under this subchapter operates unless 16legislation has been enacted specifically directing the modification, suspension, 17withdrawal, or termination. Before December 31, 2023, the commissioner may 18request renewal, without substantive change, of the waiver under 42 USC 18052 19under which the health care stability plan operates in accordance with s. 20.940 (4) 20unless legislation has been enacted that is contrary to such a renewal request. The 21commissioner shall comply with applicable timing in and requirements of s. 20.940. AB50,289522Section 2895. 601.83 (1) (h) of the statutes is renumbered 601.83 (1) (h) 23(intro.) and amended to read: AB50,1417,424601.83 (1) (h) (intro.) In 2019 and in each subsequent year, the The
1commissioner may expend no more than $200,000,000 the following amounts from 2all revenue sources for the healthcare stability plan under this section, unless the 3joint committee on finance under s. 13.10 governor has increased this amount upon 4request by the commissioner.: AB50,1417,85(he) The commissioner shall ensure that sufficient funds are available for the 6healthcare stability plan under this section to operate as described in the approval 7of the federal department of health and human services dated July 29, 2018, and in 8any waiver extension approvals. AB50,28969Section 2896. 601.83 (1) (h) 1. to 3. of the statutes are created to read: AB50,1417,1010601.83 (1) (h) 1. In 2025, $230,000,000. AB50,1417,11112. In 2026, $250,000,000. AB50,1417,20123. In 2027 and in each year thereafter, the maximum expenditure amount for 13the previous year, adjusted to reflect the percentage increase, if any, in the 14consumer price index for all urban consumers, U.S. city average, for the medical 15care group, as determined by the U.S. department of labor, for the 12-month period 16ending on December 31 of the year before the year in which the amount is 17determined. The commissioner shall determine the annual adjustment amount for 18a particular year in January of the previous year. The commissioner shall publish 19the new maximum expenditure amount under this subdivision each year in the 20Wisconsin Administrative Register. AB50,289721Section 2897. 601.83 (1) (hm) of the statutes is repealed. AB50,289822Section 2898. 609.04 of the statutes is created to read: AB50,1417,2423609.04 Preventing surprise medical bills; emergency medical 24services. (1) Definitions. In this section: AB50,1418,1
1(a) “Emergency medical condition” means all of the following: AB50,1418,521. A medical condition, including a mental health condition or substance use 3disorder condition, manifesting itself by acute symptoms of sufficient severity, 4including severe pain, such that the absence of immediate medical attention could 5reasonably be expected to result in any of the following: AB50,1418,76a. Placing the health of the individual or, with respect to a pregnant woman, 7the health of the woman or her unborn child in serious jeopardy. AB50,1418,88b. Serious impairment of bodily function. AB50,1418,99c. Serious dysfunction of any bodily organ or part. AB50,1418,13102. With respect to a pregnant woman who is having contractions, a medical 11condition for which there is inadequate time to safely transfer the pregnant woman 12to another hospital before delivery or for which the transfer may pose a threat to the 13health or safety of the pregnant woman or the unborn child. AB50,1418,1614(b) “Emergency medical services,” with respect to an emergency medical 15condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a) 16(3) (C). AB50,1418,1817(c) “Independent freestanding emergency department” has the meaning given 18in 42 USC 300gg-111 (a) (3) (D). AB50,1418,2019(d) “Out-of-network rate” has the meaning given by the commissioner by rule 20or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K). AB50,1419,221(e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any 22preferred provider plan, as defined in s. 609.01 (4), that has a network of
1participating providers and imposes on enrollees different requirements for using 2providers that are not participating providers. AB50,1419,43(f) “Recognized amount” has the meaning given by the commissioner by rule 4or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H). AB50,1419,85(g) “Self-insured governmental plan” means a self-insured health plan of the 6state or a county, city, village, town, or school district that has a network of 7participating providers and imposes on enrollees in the self-insured health plan 8different requirements for using providers that are not participating providers. AB50,1419,119(h) “Terminated” means the expiration or nonrenewal of a contract. 10“Terminated” does not include a termination of a contract for failure to meet 11applicable quality standards or for fraud. AB50,1419,1612(2) Emergency medical services. A defined network plan, preferred 13provider plan, or self-insured governmental plan that covers any benefits or 14services provided in an emergency department of a hospital or emergency medical 15services provided in an independent freestanding emergency department shall 16cover emergency medical services in accordance with all of the following: AB50,1419,1717(a) The plan may not require a prior authorization determination. AB50,1419,2018(b) The plan may not deny coverage on the basis of whether or not the health 19care provider providing the services is a participating provider or participating 20facility. AB50,1419,2321(c) If the emergency medical services are provided to an enrollee by a provider 22or in a facility that is not a participating provider or participating facility, the plan 23complies with all of the following: AB50,1420,4
11. The emergency medical services are covered without imposing on an 2enrollee a requirement for prior authorization or any coverage limitation that is 3more restrictive than requirements or limitations that apply to emergency medical 4services provided by participating providers or in participating facilities. AB50,1420,852. Any cost-sharing requirement imposed on an enrollee for the emergency 6medical services is no greater than the requirements that would apply if the 7emergency medical services were provided by a participating provider or in a 8participating facility. AB50,1420,1393. Any cost-sharing amount imposed on an enrollee for the emergency medical 10services is calculated as if the total amount that would have been charged for the 11emergency medical services if provided by a participating provider or in a 12participating facility is equal to the recognized amount for such services, plan or 13coverage, and year. AB50,1420,14144. The plan does all of the following: AB50,1420,1715a. No later than 30 days after the participating provider or participating 16facility transmits to the plan the bill for emergency medical services, sends to the 17provider or facility an initial payment or a notice of denial of payment. AB50,1420,2018b. Pays to the participating provider or participating facility a total amount 19that, incorporating any initial payment under subd. 4. a., is equal to the amount by 20which the out-of-network rate exceeds the cost-sharing amount. AB50,1421,2215. The plan counts any cost-sharing payment made by the enrollee for the 22emergency medical services toward any in-network deductible or out-of-pocket 23maximum applied by the plan in the same manner as if the cost-sharing payment
1was made for emergency medical services provided by a participating provider or in 2a participating facility. AB50,1421,83(3) Nonparticipating provider in participating facility. For items or 4services other than emergency medical services that are provided to an enrollee of 5a defined network plan, preferred provider plan, or self-insured governmental plan 6by a provider who is not a participating provider but who is providing services at a 7participating facility, the plan shall provide coverage for the item or service in 8accordance with all of the following: AB50,1421,119(a) The plan may not impose on an enrollee a cost-sharing requirement for the 10item or service that is greater than the cost-sharing requirement that would have 11been imposed if the item or service was provided by a participating provider. AB50,1421,1512(b) Any cost-sharing amount imposed on an enrollee for the item or service is 13calculated as if the total amount that would have been charged for the item or 14service if provided by a participating provider is equal to the recognized amount for 15such item or service, plan or coverage, and year. AB50,1421,1716(c) No later than 30 days after the provider transmits the bill for services, the 17plan shall send to the provider an initial payment or a notice of denial of payment. AB50,1421,2118(d) The plan shall make a total payment directly to the provider who provided 19the item or service to the enrollee that, added to any initial payment described 20under par. (c), is equal to the amount by which the out-of-network rate for the item 21or service exceeds the cost-sharing amount. AB50,1422,222(e) The plan counts any cost-sharing payment made by the enrollee for the 23item or service toward any in-network deductible or out-of-pocket maximum
1applied by the plan in the same manner as if the cost-sharing payment was made 2for the item or service when provided by a participating provider. AB50,1422,83(4) Charging for services by nonparticipating provider; notice and 4consent. (a) Except as provided in par. (c), a provider of an item or service who is 5entitled to payment under sub. (3) may not bill or hold liable an enrollee for any 6amount for the item or service that is more than the cost-sharing amount 7calculated under sub. (3) (b) for the item or service unless the nonparticipating 8provider provides notice and obtains consent in accordance with all of the following: AB50,1422,1191. The notice states that the provider is not a participating provider in the 10enrollee’s defined network plan, preferred provider plan, or self-insured 11governmental plan. AB50,1422,15122. The notice provides a good faith estimate of the amount that the 13nonparticipating provider may charge the enrollee for the item or service involved, 14including notification that the estimate does not constitute a contract with respect 15to the charges estimated for the item or service. AB50,1422,18163. The notice includes a list of the participating providers at the participating 17facility who would be able to provide the item or service and notification that the 18enrollee may be referred to one of those participating providers. AB50,1422,21194. The notice includes information about whether or not prior authorization or 20other care management limitations may be required before receiving an item or 21service at the participating facility. AB50,1422,23225. The notice clearly states that consent is optional and that the patient may 23elect to seek care from an in-network provider. AB50,1423,1
16. The notice is worded in plain language. AB50,1423,327. The notice is available in languages other than English. The commissioner 3shall identify languages for which the notice should be available. AB50,1423,848. The enrollee provides consent to the nonparticipating provider to be treated 5by the nonparticipating provider, and the consent acknowledges that the enrollee 6has been informed that the charge paid by the enrollee may not meet a limitation 7that the enrollee’s defined network plan, preferred provider plan, or self-insured 8governmental plan places on cost sharing, such as an in-network deductible. AB50,1423,1099. A signed copy of the consent described under subd. 8. is provided to the 10enrollee. AB50,1423,1211(b) To be considered adequate, the notice and consent under par. (a) shall meet 12one of the following requirements, as applicable: AB50,1423,16131. If the enrollee makes an appointment for the item or service at least 72 14hours before the day on which the item or service is to be provided, any notice under 15par. (a) shall be provided to the enrollee at least 72 hours before the day of the 16appointment at which the item or service is to be provided. AB50,1423,19172. If the enrollee makes an appointment for the item or service less than 72 18hours before the day on which the item or service is to be provided, any notice under 19par. (a) shall be provided to the enrollee on the day that the appointment is made. AB50,1424,320(c) A provider of an item or service who is entitled to payment under sub. (3) 21may not bill or hold liable an enrollee for any amount for an ancillary item or 22service that is more than the cost-sharing amount calculated under sub. (3) (b) for 23the item or service, whether or not provided by a physician or non-physician
1practitioner, unless the commissioner specifies by rule that the provider may bill or 2hold the enrollee liable for the ancillary item or service, if the item or service is any 3of the following: AB50,1424,441. Related to an emergency medical service. AB50,1424,552. Anesthesiology. AB50,1424,663. Pathology.
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