AB50,2897 Section 2897. 601.83 (1) (hm) of the statutes is repealed.

AB50,2898 Section 2898. 609.04 of the statutes is created to read:

AB50,1417,24 609.04 Preventing surprise medical bills; emergency medical services. (1) Definitions. In this section:

AB50,1418,1 (a) “Emergency medical condition” means all of the following:

AB50,1418,5 1. A medical condition, including a mental health condition or substance use disorder condition, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

AB50,1418,7 a. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy.

AB50,1418,8 b. Serious impairment of bodily function.

AB50,1418,9 c. Serious dysfunction of any bodily organ or part.

AB50,1418,13 2. With respect to a pregnant woman who is having contractions, a medical condition for which there is inadequate time to safely transfer the pregnant woman to another hospital before delivery or for which the transfer may pose a threat to the health or safety of the pregnant woman or the unborn child.

AB50,1418,16 (b) “Emergency medical services,” with respect to an emergency medical condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a) (3) (C).

AB50,1418,18 (c) “Independent freestanding emergency department” has the meaning given in 42 USC 300gg-111 (a) (3) (D).

AB50,1418,20 (d) “Out-of-network rate” 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) (K).

AB50,1419,2 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any preferred provider plan, as defined in s. 609.01 (4), that has a network of participating providers and imposes on enrollees different requirements for using providers that are not participating providers.

AB50,1419,4 (f) “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).

AB50,1419,8 (g) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

AB50,1419,11 (h) “Terminated” means the expiration or nonrenewal of a contract. “Terminated” does not include a termination of a contract for failure to meet applicable quality standards or for fraud.

AB50,1419,16 (2) Emergency medical services. A defined network plan, preferred provider plan, or self-insured governmental plan that covers any benefits or services provided in an emergency department of a hospital or emergency medical services provided in an independent freestanding emergency department shall cover emergency medical services in accordance with all of the following:

AB50,1419,17 (a) The plan may not require a prior authorization determination.

AB50,1419,20 (b) The plan may not deny coverage on the basis of whether or not the health care provider providing the services is a participating provider or participating facility.

AB50,1419,23 (c) If the emergency medical services are provided to an enrollee by a provider or in a facility that is not a participating provider or participating facility, the plan complies with all of the following:

AB50,1420,4 1. The emergency medical services are covered without imposing on an enrollee a requirement for prior authorization or any coverage limitation that is more restrictive than requirements or limitations that apply to emergency medical services provided by participating providers or in participating facilities.

AB50,1420,8 2. Any cost-sharing requirement imposed on an enrollee for the emergency medical services is no greater than the requirements that would apply if the emergency medical services were provided by a participating provider or in a participating facility.

AB50,1420,13 3. Any cost-sharing amount imposed on an enrollee for the emergency medical services is calculated as if the total amount that would have been charged for the emergency medical services if provided by a participating provider or in a participating facility is equal to the recognized amount for such services, plan or coverage, and year.

AB50,1420,14 4. The plan does all of the following:

AB50,1420,17 a. No later than 30 days after the participating provider or participating facility transmits to the plan the bill for emergency medical services, sends to the provider or facility an initial payment or a notice of denial of payment.

AB50,1420,20 b. Pays to the participating provider or participating facility a total amount that, incorporating any initial payment under subd. 4. a., is equal to the amount by which the out-of-network rate exceeds the cost-sharing amount.

AB50,1421,2 5. The plan counts any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket maximum applied by the plan in the same manner as if the cost-sharing payment was made for emergency medical services provided by a participating provider or in a participating facility.

AB50,1421,8 (3) Nonparticipating provider in participating facility. For items or services other than emergency medical services that are provided to an enrollee of a defined network plan, preferred provider plan, or self-insured governmental plan by a provider who is not a participating provider but who is providing services at a participating facility, the plan shall provide coverage for the item or service in accordance with all of the following:

AB50,1421,11 (a) The plan may not impose on an enrollee a cost-sharing requirement for the item or service that is greater than the cost-sharing requirement that would have been imposed if the item or service was provided by a participating provider.