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.

AB50,1421,15 (b) Any cost-sharing amount imposed on an enrollee for the item or service is calculated as if the total amount that would have been charged for the item or service if provided by a participating provider is equal to the recognized amount for such item or service, plan or coverage, and year.

AB50,1421,17 (c) No later than 30 days after the provider transmits the bill for services, the plan shall send to the provider an initial payment or a notice of denial of payment.

AB50,1421,21 (d) The plan shall make a total payment directly to the provider who provided the item or service to the enrollee that, added to any initial payment described under par. (c), is equal to the amount by which the out-of-network rate for the item or service exceeds the cost-sharing amount.

AB50,1422,2 (e) The plan counts any cost-sharing payment made by the enrollee for the item or service 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 the item or service when provided by a participating provider.

AB50,1422,8 (4) Charging for services by nonparticipating provider; notice and consent. (a) Except as provided in par. (c), a provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for the item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service unless the nonparticipating provider provides notice and obtains consent in accordance with all of the following:

AB50,1422,11 1. The notice states that the provider is not a participating provider in the enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan.

AB50,1422,15 2. The notice provides a good faith estimate of the amount that the nonparticipating provider may charge the enrollee for the item or service involved, including notification that the estimate does not constitute a contract with respect to the charges estimated for the item or service.

AB50,1422,18 3. The notice includes a list of the participating providers at the participating facility who would be able to provide the item or service and notification that the enrollee may be referred to one of those participating providers.

AB50,1422,21 4. The notice includes information about whether or not prior authorization or other care management limitations may be required before receiving an item or service at the participating facility.

AB50,1422,23 5. The notice clearly states that consent is optional and that the patient may elect to seek care from an in-network provider.

AB50,1423,1 6. The notice is worded in plain language.

AB50,1423,3 7. The notice is available in languages other than English. The commissioner shall identify languages for which the notice should be available.

AB50,1423,8 8. The enrollee provides consent to the nonparticipating provider to be treated by the nonparticipating provider, and the consent acknowledges that the enrollee has been informed that the charge paid by the enrollee may not meet a limitation that the enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan places on cost sharing, such as an in-network deductible.

AB50,1423,10 9. A signed copy of the consent described under subd. 8. is provided to the enrollee.

AB50,1423,12 (b) To be considered adequate, the notice and consent under par. (a) shall meet one of the following requirements, as applicable:

AB50,1423,16 1. If the enrollee makes an appointment for the item or service at least 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee at least 72 hours before the day of the appointment at which the item or service is to be provided.

AB50,1423,19 2. If the enrollee makes an appointment for the item or service less than 72 hours before the day on which the item or service is to be provided, any notice under par. (a) shall be provided to the enrollee on the day that the appointment is made.

AB50,1424,3 (c) A provider of an item or service who is entitled to payment under sub. (3) may not bill or hold liable an enrollee for any amount for an ancillary item or service that is more than the cost-sharing amount calculated under sub. (3) (b) for the item or service, whether or not provided by a physician or non-physician practitioner, unless the commissioner specifies by rule that the provider may bill or hold the enrollee liable for the ancillary item or service, if the item or service is any of the following:

AB50,1424,4 1. Related to an emergency medical service.

AB50,1424,5 2. Anesthesiology.

AB50,1424,6 3. Pathology.

AB50,1424,7 4. Radiology.

AB50,1424,8 5. Neonatology.

AB50,1424,10 6. An item or service provided by an assistant surgeon, hospitalist, or intensivist.

AB50,1424,11 7. A diagnostic service, including a radiology or laboratory service.

AB50,1424,13 8. An item or service provided by a specialty practitioner that the commissioner specifies by rule.