AB68-SSA1,3014 16Section 3014. 632.895 (14) (d) 3. of the statutes is amended to read:
AB68-SSA1,1386,1917 632.895 (14) (d) 3. A health care plan offered by a limited service health
18organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined
19in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b)
.
AB68-SSA1,3015 20Section 3015. 632.895 (14m) of the statutes is created to read:
AB68-SSA1,1386,2221 632.895 (14m) Essential health benefits. (a) In this subsection,
22“self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB68-SSA1,1387,223 (b) On a date specified by the commissioner, by rule, every disability insurance
24policy, except as provided in par. (g), and every self-insured health plan shall provide

1coverage for essential health benefits as determined by the commissioner, by rule,
2subject to par. (c).
AB68-SSA1,1387,43 (c) In determining the essential health benefits for which coverage is required
4under par. (b), the commissioner shall do all of the following:
AB68-SSA1,1387,65 1. Include benefits, items, and services in, at least, all of the following
6categories:
AB68-SSA1,1387,77 a. Ambulatory patient services.
AB68-SSA1,1387,88 b. Emergency services.
AB68-SSA1,1387,99 c. Hospitalization.
AB68-SSA1,1387,1010 d. Maternity and newborn care.
AB68-SSA1,1387,1211 e. Mental health and substance use disorder services, including behavioral
12health treatment.
AB68-SSA1,1387,1313 f. Prescription drugs.
AB68-SSA1,1387,1414 g. Rehabilitative and habilitative services and devices.
AB68-SSA1,1387,1515 h. Laboratory services.
AB68-SSA1,1387,1616 i. Preventive and wellness services and chronic disease management.
AB68-SSA1,1387,1717 j. Pediatric services, including oral and vision care.
AB68-SSA1,1387,2218 2. Conduct a survey of employer-sponsored coverage to determine benefits
19typically covered by employers and ensure that the scope of essential health benefits
20for which coverage is required under this subsection is equal to the scope of benefits
21covered under a typical disability insurance policy offered by an employer to its
22employees.
AB68-SSA1,1387,2423 3. Ensure that essential health benefits reflect a balance among the categories
24described in subd. 1. such that benefits are not unduly weighted toward one category.
AB68-SSA1,1388,2
14. Ensure that essential health benefit coverage is provided with no or limited
2cost-sharing requirements.
AB68-SSA1,1388,63 5. Require that disability insurance policies and self-insured health plans do
4not make coverage decisions, determine reimbursement rates, establish incentive
5programs, or design benefits in ways that discriminate against individuals because
6of their age, disability, or expected length of life.
AB68-SSA1,1388,97 6. Establish essential health benefits in a way that takes into account the
8health care needs of diverse segments of the population, including women, children,
9persons with disabilities, and other groups.
AB68-SSA1,1388,1310 7. Ensure that essential health benefits established under this subsection are
11not subject to a coverage denial based on an insured's or plan participant's age,
12expected length of life, present or predicted disability, degree of dependency on
13medical care, or quality of life.
AB68-SSA1,1388,2014 8. Require that disability insurance policies and self-insured health plans
15cover emergency department services that are essential health benefits without
16imposing any requirement to obtain prior authorization for those services and
17without limiting coverage for services provided by an emergency services provider
18that is not in the provider network of a policy or plan in a way that is more restrictive
19than requirements or limitations that apply to emergency services provided by a
20provider that is in the provider network of the policy or plan.
AB68-SSA1,1388,2521 9. Require a disability insurance policy or self-insured health plan to apply to
22emergency department services that are essential health benefits provided by an
23emergency department provider that is not in the provider network of the policy or
24plan the same copayment amount or coinsurance rate that applies if those services
25are provided by a provider that is in the provider network of the policy or plan.
AB68-SSA1,1389,2
1(d) The commissioner shall periodically update, by rule, the essential health
2benefits under this subsection to address any gaps in access to coverage.
AB68-SSA1,1389,73 (e) If an essential health benefit is also subject to mandated coverage elsewhere
4under this section and the coverage requirements are not identical, the disability
5insurance policy or self-insured health plan shall provide coverage under whichever
6subsection provides the insured or plan participant with more comprehensive
7coverage of the medical condition, item, or service.
AB68-SSA1,1389,118 (f) Nothing in this subsection or rules promulgated under this subsection
9prohibits a disability insurance policy or a self-insured health plan from providing
10benefits in excess of the essential health benefit coverage required under this
11subsection.
AB68-SSA1,1389,1312 (g) This subsection does not apply to any disability insurance policy that is
13described in s. 632.745 (11) (b) 1. to 12.