December 8, 2023 - Introduced by Senators Smith, Larson, L. Johnson and Wirch, cosponsored by Representatives J. Anderson, Andraca, Bare, Clancy, Conley, Drake, Emerson, Jacobson, Joers, Madison, Moore Omokunde, Ortiz-Velez, Palmeri, Shelton, Snodgrass, Sortwell, Stubbs and Subeck. Referred to Committee on Insurance and Small Business.

SB743,,2 An Act to create 609.045 of the statutes; relating to: insurance coverage and balance billing for certain health care services and granting rule-making authority.

SB743,,3 Analysis by the Legislative Reference Bureau

This bill requires defined network plans, such as health maintenance organizations, and certain preferred provider plans and self-insured governmental plans that cover benefits or services provided in either an emergency department of a hospital or independent freestanding emergency department to cover emergency medical services without requiring a prior authorization determination and without regard to whether the health care provider providing the emergency medical services is a participating provider or facility. If the emergency medical services for which coverage is required are provided by a nonparticipating provider, the plan must 1) not impose a prior authorization requirement or other limitation that is more restrictive than if the service was provided by a participating provider; 2) not impose cost sharing on an enrollee that is greater than the cost sharing required if the service was provided by a participating provider; 3) calculate the cost-sharing amount to be equal to the amount that would have been charged if the service was provided by a participating provider; 4) provide, within 30 days of the provider’s or facility’s bill, an initial payment or denial notice to the provider or facility and then pay a total amount to the provider or facility that is equal to the amount by which the provider’s or facility’s rate exceeds the amount it received in cost sharing from the enrollee; and 5) count any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for services provided by a participating provider or facility. The provider or facility may not bill or hold liable an enrollee of the plan for any amount for the emergency medical service that is more than the cost-sharing amount that is calculated as described in the bill for the emergency medical service.

For coverage of an item or service that is provided by a nonparticipating provider in a participating facility, a plan must 1) not impose 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; 2) calculate the cost-sharing amount to be equal to the amount that would have been charged if the service was provided by a participating provider; 3) provide, within 30 days of the provider’s bill, an initial payment or denial notice to the provider and then pay a total amount to the provider that is equal to the amount by which the provider’s rate exceeds the amount it received in cost sharing from the enrollee; and 4) count any cost-sharing payment made by the enrollee for the items or services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for items or services provided by a participating provider. A nonparticipating provider providing an item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount unless the provider provides notice and obtains consent as described in the bill. However, if the nonparticipating provider is providing an ancillary item or service that is specified in the bill, and the commissioner of insurance has not specifically allowed balance billing for that item or service by rule, the nonparticipating provider providing the ancillary item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount.

Under the bill, a provider or facility that is entitled to a payment for an emergency medical service or other item or service may initiate open negotiations with the defined network plan, preferred provider plan, or self-insured governmental health plan to determine the amount of payment. If the open negotiation period terminates without determination of the payment amount, the provider, facility, or plan may initiate the independent dispute resolution process as specified by the commissioner of insurance. If an enrollee of a plan is a continuing care patient, as defined in the bill, and is obtaining services from a participating provider or facility, and the contract is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract is terminated, resulting in a loss of benefits under the plan, the plan must notify the enrollee of the enrollee’s right to elect to continue transitional care, provide the enrollee an opportunity to notify the plan of the need for transitional care, and allow the enrollee to continue to have the benefits provided under the plan under the same terms and conditions as would have applied without the termination until either 90 days after the termination notice date or the date on which the enrollee is no longer a continuing care patient, whichever is earlier. If a continuing care patient would qualify for continued care for a longer period under current law than specified in the bill, the bill specifies that the continuing care patient may continue to receive coverage for the longer period provided under current law.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.

SB743,,4 The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB743,1 Section 1. 609.045 of the statutes is created to read:

SB743,,6 609.045 Balance billing; emergency medical services. (1) Definitions. In this section:

SB743,,7 (a) “Emergency medical services” means emergency medical services for which coverage is required under s. 632.85 (2) and includes emergency medical services described under s. 632.85 (2) as if section 1867 of the federal Social Security Act applied to an independent freestanding emergency department.

SB743,,8 (b) “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.

SB743,,9 (c) “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.

SB743,,10 (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:

SB743,,11 (a) The plan may not require a prior authorization determination.

SB743,,12 (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 emergency facility.

SB743,,13 (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:

SB743,,14 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.

SB743,,15 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.

SB743,,16 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 amount paid to the provider or facility that is not a participating provider or participating facility as determined by the commissioner.

SB743,,17 4. The plan does all of the following:

SB743,,18 a. No later than 30 days after the provider or 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.

SB743,,19 b. Pays to the provider or facility a total amount that, incorporating any initial payment under subd. 4. a., is equal to the amount by which the rate for a provider or facility that is not a participating provider or facility exceeds the cost-sharing amount.

SB743,,20 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.

SB743,,21 (3) Provider billing limitation for emergency medical services; ambulance services. A provider of emergency medical services or a facility in which emergency medical services are provided that is entitled to payment under sub. (2) may not bill or hold liable an enrollee for any amount for the emergency medical service that is more than the cost-sharing amount determined under sub. (2) (c) 3. for the emergency service. A provider of ambulance services that is not a participating provider under an enrollee’s defined network plan, preferred provider plan, or self-insured governmental plan may not bill or hold liable an enrollee for any amount of the ambulance service that is more than the cost-sharing amount that the enrollee would be charged if the provider of ambulance services was a participating provider under the enrollee’s plan.

SB743,,22 (4) 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 that is not a participating provider but is providing services at a participating facility, the plan shall provide coverage for the item or service in accordance with all of the following: