2015 - 2016 LEGISLATURE
May 5, 2015 - Introduced by Representatives Czaja,
Bernier, Edming, Knodl,
Krug, T. Larson, Mursau, Rohrkaste and Thiesfeldt, cosponsored by
Senators Vukmir, Cowles and Nass. Referred to Committee on Insurance.
1An Act to amend
185.983 (1) (intro.); and to create
609.72 and 632.799 of the 2
statutes; relating to: information to be provided by insurers about health care
3plans offered on the American health benefit exchange.
Analysis by the Legislative Reference Bureau
Under the federal Patient Protection and Affordable Care Act (ACA), which was
enacted on March 23, 2010, each state must establish an American health benefit
exchange (exchange) through which individuals and certain businesses may
purchase health insurance. The federal government will establish and operate an
exchange in a state that does not establish its own. Health insurance offered through
the exchange must meet certain federal requirements, including offering the
essential health benefits package that is established by the federal Department of
Health and Human Services. Such a health benefit plan is called a qualified health
plan (plan) under the ACA.
This bill requires a insurer that offers plans through an exchange that is
operating in this state to provide access on the insurer's Internet site to information,
in a clear and understandable form, that will enable consumers shopping for health
insurance on the exchange to determine all of the following about the insurer's plans
offered through the exchange: exclusions from coverage and restrictions on use or
quantity of covered services or items; any service or item with a cost-sharing
requirement that depends on the cost of the service or item; whether a specific
prescription drug is covered and any clinical prerequisites or authorization
requirements for coverage of a prescription drug; whether specific types of specialists
are included, and whether a specific named specialist is included, in the plan's
network; the process for appealing a denial of coverage of a service or item; and how
the out-of-pocket costs of medications will or will not be applied towards the
deductible under the plan.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
185.983 (1) (intro.) of the statutes is amended to read:
(intro.) Every voluntary nonprofit health care plan operated by a 3
cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 4
646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 5
601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 6
631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.799, 7
632.85, 632.853, 632.855, 632.867, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 8
632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 9
635, 645, and 646, but the sponsoring association shall:
609.72 of the statutes is created to read:
11609.72 Required plan information.
Defined network plans are subject to 12
632.799 of the statutes is created to read:
14632.799 Information about plans offered through an American health
15benefit exchange. (1) Definitions.
In this section:
(a) "Exchange" means an American health benefit exchange, as described in 42
, that is operating in this state.
(b) "Qualified health plan" has the meaning given in 42 USC 18021
19(2) Information that must be provided.
(a) To enable consumers to compare 20
coverage among qualified health plans offered through an exchange, an insurer that
offers a qualified health plan through an exchange shall, in addition to any other 2
information that is required under federal law, provide access to information about 3
the qualified health plan, in a clear and understandable form, such that consumers 4
are able to determine all of the following with respect to the qualified health plan:
1. Any exclusions from coverage and any restrictions on use or quantity of 6
covered services and items in each category of benefits, including prescription drugs 7
and drugs administered in a physician's office or in a clinic.
2. Any service or item with a cost-sharing requirement, including a 9
prescription drug, for which the cost sharing required depends on the cost of the 10
service or item.
3. Whether a specific prescription drug is covered by the qualified health plan, 12
whether a specific prescription drug is covered when furnished by a physician or 13
clinic, and any clinical prerequisites or authorization requirements for coverage of 14
a prescription drug.
4. Whether specific types of specialists are included in the qualified health 16
plan's network and whether a specific named physician is in the qualified health 17
5. The process for an insured to appeal a decision of the qualified health plan 19
denying coverage of a service or item prescribed or ordered by a treating physician.
6. How the cost of medications will be included in or excluded from the 21
deductible under the qualified health plan, including a description of out-of-pocket 22
costs for a medication that do not apply towards the deductible.
(b) The information required under par. (a) shall be made available on the 24
insurer's Internet site.
(c) Nothing in this section requires an insurer to provide information that 2
duplicates information that the insurer already provides.