AB43,,8572 (5) Notice by provider or facility. Beginning no later than January 1, 2024, a health care provider or health care facility shall make available, including posting on a website, to enrollees in defined network plans, preferred provider plans, and self-insured governmental plans notice of the requirements on a provider or facility under sub. (4), of any other applicable state law requirements on the provider or facility with respect to charging an enrollee for an item or service if the provider or facility does not have a contractual relationship with the plan, and of information on contacting appropriate state or federal agencies in the event the enrollee believes the provider or facility violates any of the requirements under this section or other applicable law.

AB43,,8573 (6) Negotiation; dispute resolution. A provider or facility that is entitled to receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may initiate, within 30 days of receiving the initial payment or notice of denial, open negotiations with the defined network plan, preferred provider plan, or self-insured governmental plan to determine a payment amount for an emergency medical service or other item or service for a period that terminates 30 days after initiating open negotiations. If the open negotiation period under this subsection terminates without determination of a payment amount, the provider, facility, defined network plan, preferred provider plan, or self-insured governmental plan may initiate, within the 4 days beginning on the day after the open negotiation period ends, the independent dispute resolution process as specified by the commissioner. If the independent dispute resolution decision-maker determines the payment amount, the party to the independent dispute resolution process whose amount was not selected shall pay the fees for the independent dispute resolution. If the parties to the independent dispute resolution reach a settlement on the payment amount, the parties to the independent dispute resolution shall equally divide the payment for the fees for the independent dispute resolution.

AB43,,8574 (7) Continuity of care. (a) In this subsection:

AB43,,8575 1. “Continuing care patient” means an individual who is any of the following:

AB43,,8576 a. Undergoing a course of treatment for a serious and complex condition from a provider or facility.

AB43,,8577 b. Undergoing a course of institutional or inpatient care from a provider or facility.

AB43,,8578 c. Scheduled to undergo nonelective surgery, including receipt of postoperative care, from a provider or facility.

AB43,,8579 d. Pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.

AB43,,8580 e. Terminally ill and receiving treatment for the illness from a provider or facility.

AB43,,8581 2. “Serious and complex condition” means any of the following:

AB43,,8582 a. In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.

AB43,,8583 b. In the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized medical care over a prolonged period.

AB43,,8584 (b) If an enrollee is a continuing care patient and is obtaining items or services from a participating provider or participating facility and the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract between the defined network plan, preferred provider plan, or self-insured governmental plan and the provider or facility is terminated, resulting in a loss of benefits provided under the plan, the plan shall do all of the following:

AB43,,8585 1. Notify each enrollee of the termination of the contract or benefits and of the right for the enrollee to elect to continue transitional care from the participating provider or participating facility under this subsection.

AB43,,8586 2. Provide the enrollee an opportunity to notify the plan of the need for transitional care.

AB43,,8587 3. Allow the enrollee to elect to continue to have the benefits provided under the plan under the same terms and conditions as would have applied to the item or service if the termination had not occurred for the course of treatment related to the enrollee’s status as a continuing care patient beginning on the date on which the notice under subd. 1. is provided and ending 90 days after the date on which the notice under subd. 1. is provided or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.

AB43,,8588 (c) The provisions of s. 609.24 apply to a continuing care patient to the extent that s. 609.24 does not conflict with this subsection so as to limit the enrollee’s rights under this subsection.

AB43,,8589 (8) Rule making. The commissioner may promulgate any rules necessary to implement this section, including specifying the independent dispute resolution process under sub. (6). The commissioner may promulgate rules to modify the list of those items and services for which a provider may not balance bill under sub. (4) (c). In promulgating rules under this subsection, the commissioner may consider any rules promulgated by the federal department of health and human services pursuant to the federal No Suprises Act, 42 USC 300gg-111, et seq.

AB43,3051 Section 3051. 609.20 (3) of the statutes is created to read:

AB43,,8591 609.20 (3) The commissioner may promulgate rules to establish minimum network time and distance standards and minimum network wait-time standards for defined network plans and preferred provider plans. In promulgating rules under this subsection, the commissioner shall consider standards adopted by the federal centers for medicare and medicaid services for qualified health plans, as defined in 42 USC 18021 (a), that are offered through the federal health insurance exchange established pursuant to 42 USC 18041 (c).

AB43,3052 Section 3052. 609.24 (5) of the statutes is created to read:

AB43,,8593 609.24 (5) If an enrollee is a continuing care patient, as defined in s. 609.045 (7) (a), and if any of the situations described under s. 609.045 (7) (b) (intro.) applies, all of the following apply to the enrollee’s defined network plan:

AB43,,8594 (a) Subsection (1) (c) shall apply to any of the participating providers providing the enrollee’s course of treatment under s. 609.045 (7), including the enrollee’s primary care physician.

AB43,,8595 (b) Subsection (1) (c) shall apply to lengthen the period in which benefits are provided under s. 609.045 (7) (b) 3., but shall not be applied to shorten the period in which benefits are provided under s. 609.045 (7) (b) 3.

AB43,,8596 (c) Subsection (1) (d) shall not be applied in a manner that limits the enrollee’s rights under s. 609.045 (7) (b) 3.

AB43,,8597 (d) No plan may contract or arrange with a participating provider to provide notice of the termination of the participating provider’s participation, pursuant to sub. (4).

AB43,3053 Section 3053. 609.712 of the statutes is created to read:

AB43,,8599 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

AB43,3054 Section 3054. 609.713 of the statutes is created to read: