2017 - 2018 LEGISLATURE
June 2, 2017 - Introduced by Representatives Riemer, Kolste, C. Taylor,
Anderson, Barca, Berceau, Billings, Bowen, Brostoff, Considine, Crowley,
Doyle, Fields, Genrich, Goyke, Hebl, Hesselbein, Hintz, Kessler, Mason,
Meyers, Ohnstad, Pope, Sargent, Shankland, Sinicki, Spreitzer, Stuck,
Subeck, Vruwink, Wachs, Young, Zamarripa and Zepnick, cosponsored by
Senators Erpenbach, Johnson, Shilling, Bewley, Carpenter, Hansen,
Larson, Miller, Ringhand, Risser, L. Taylor, Vinehout and Wirch. Referred
to Committee on Insurance.
1An Act to create
609.713 and 632.895 (14m) of the statutes; relating to:
2coverage of certain essential health benefits by health insurance policies and
3plans and requiring the exercise of rule-making authority.
Analysis by the Legislative Reference Bureau
This bill requires health insurance policies, known in the bill as disability
insurance policies, and governmental self-insured health plans to cover essential
health benefits that will be specified by the commissioner of the Office of the
Commissioner of Insurance by rule. The bill specifies a list of requirements that the
commissioner must follow when establishing the essential health benefits including
certain limitations on cost sharing and the following general categories of benefits,
items, or services in which the commissioner must require coverage: ambulatory
patient services, emergency services, hospitalization, maternity and newborn care,
mental health and substance use disorder services, prescription drugs,
rehabilitative and habilitative services and devices, laboratory services, preventive
and wellness services and chronic disease management, and pediatric services. If
an essential health benefit specified by the commissioner is also subject to its own
mandated coverage requirement, the bill requires the disability insurance policy or
self-insured health plan to provide coverage under whichever requirement provides
the insured or plan participant with more comprehensive coverage.
This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
609.713 of the statutes is created to read:
2609.713 Essential health benefits.
Defined network plans and preferred 3
provider plans are subject to s. 632.895 (14m).
632.895 (14m) of the statutes is created to read:
632.895 (14m) Essential health benefits.
(a) In this section, “self-insured 6
health plan” has the meaning given in s. 632.85 (1) (c).
(b) On a date specified by the commissioner, by rule, every disability insurance 8
policy and every self-insured health plan shall provide coverage for essential health 9
benefits as determined by the commissioner, by rule, subject to par. (c).
(c) In determining the essential health benefits for which coverage is required 11
under par. (b), the commissioner shall do all of the following:
1. Include benefits, items, and services in, at least, all of the following 13
a. Ambulatory patient services.
b. Emergency services.
d. Maternity and newborn care.
e. Mental health and substance use disorder services, including behavioral 19
f. Prescription drugs.
g. Rehabilitative and habilitative services and devices.
h. Laboratory services.
i. Preventive and wellness services and chronic disease management.
j. Pediatric services, including oral and vision care.
2. Conduct a survey of employer-sponsored coverage to determine benefits 5
typically covered by employers and ensure that the scope of essential health benefits 6
for which coverage is required under this subsection is equal to the scope of benefits 7
covered under a typical disability insurance policy offered by an employer to its 8
3. Ensure that essential health benefits reflect a balance among the categories 10
described in subd. 1. such that benefits are not unduly weighted toward one category.
4. Ensure that essential health benefit coverage is provided with no or limited 12
5. Require that disability insurance policies and self-insured health plans do 14
not make coverage decisions, determine reimbursement rates, establish incentive 15
programs, or design benefits in ways that discriminate against individuals because 16
of their age, disability, or expected length of life.
6. Establish essential health benefits in a way that takes account of the health 18
care needs of diverse segments of the population, including women, children, persons 19
with disabilities, and other groups.
7. Ensure that essential health benefits established under this subsection not 21
be subject to a coverage denial based on an insured's or plan participant's age, 22
expected length of life, present or predicted disability, degree of dependency on 23
medical care, or quality of life.
8. Require that disability insurance policies and self-insured health plans 25
cover emergency department services that are essential health benefits without
imposing any requirement to obtain prior authorization for those services and 2
without limiting coverage for services provided by an emergency services provider 3
that is not in the provider network of a policy or plan in a way that is more restrictive 4
than requirements or limitations that apply to emergency services provided by a 5
provider that is in the provider network of the policy or plan.
9. Require a disability insurance policy or self-insured health plan to apply to 7
emergency department services that are essential health benefits provided by an 8
emergency department provider that is not in the provider network of the policy or 9
plan the same copayment amount or coinsurance rate that applies if those services 10
are provided by a provider that is in the provider network of the policy or plan.
(d) The commissioner shall periodically update, by rule, the essential health 12
benefits under this subsection to address any gaps in access to coverage.
(e) If an essential health benefit is also subject to mandated coverage elsewhere 14
under this section and the coverage requirements are not identical, the disability 15
insurance policy or self-insured health plan shall provide coverage under whichever 16
subsection provides the insured or plan participant with more comprehensive 17
coverage of the medical condition, item, or service.
(f) Nothing in this subsection or rules promulgated under this subsection 19
prohibits a disability insurance policy or a self-insured health plan from providing 20
benefits in excess of the essential health benefit coverage required under this 21