2019 - 2020 LEGISLATURE
ASSEMBLY AMENDMENT 2,
TO ASSEMBLY SUBSTITUTE AMENDMENT 1,
TO ASSEMBLY BILL 1
January 22, 2019 - Offered by Representatives Anderson, Billings, Bowen,
Brostoff, Cabrera, Considine, Crowley, Doyle, Emerson, Fields, Goyke,
Gruszynski, Haywood, Hebl, Hesselbein, Hintz, Kolste, Meyers, Milroy,
Myers, Neubauer, Ohnstad, Pope, Riemer, Sargent, Shankland, Sinicki,
Spreitzer, Stubbs, Stuck, Subeck, C. Taylor, Vining, Vruwink and
21. Page 1, line 4
: after “plans" insert “, prohibiting certain benefit limits in 3
health benefit plans, essential health benefits, and requiring the exercise of 4
1609.713 Essential health benefits.
Defined network plans and preferred 2
provider plans are subject to s. 632.895 (14m).
4609.845 Lifetime and annual limits.
Limited service health organizations, 5
preferred provider plans, and defined network plans are subject to s. 632.883.”.
8632.883 Lifetime and annual limits; prohibiting discrimination based
9on preexisting conditions. (1)
In this section:
(a) “Health benefit plan” has the meaning given in s. 632.745 (11).
(b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
An individual or group health benefit plan or a self-insured health plan 13
may not establish any of the following:
(a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent 15
of an enrollee under the plan.
(b) Annual limits on the dollar value of benefits for an enrollee or a dependent 17
of an enrollee under the plan.
For the purpose of setting rates or premiums for coverage under a group or 19
individual heath benefit plan or a self-insured health plan and for the purpose of 20
setting any deductibles, copayments, or coinsurance under a group or individual 21
health benefit plan or a self-insured health plan, the plan may not consider whether 22
an individual, including a dependent, who would be covered under the plan has a 23
632.895 (14m) of the statutes is created to read:
632.895 (14m) Essential health benefits.
(a) In this subsection, 2
“self-insured 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 4
policy, except as provided in par. (g), and every self-insured health plan shall provide 5
coverage for essential health benefits as determined by the commissioner, by rule, 6
subject to par. (c).
(c) In determining the essential health benefits for which coverage is required 8
under par. (b), the commissioner shall do all of the following:
1. Include benefits, items, and services in, at least, all of the following 10
a. Ambulatory patient services.
b. Emergency services.
d. Maternity and newborn care.
e. Mental health and substance use disorder services, including behavioral 16
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 23
typically covered by employers and ensure that the scope of essential health benefits 24
for which coverage is required under this subsection is equal to the scope of benefits
covered under a typical disability insurance policy offered by an employer to its 2
3. Ensure that essential health benefits reflect a balance among the categories 4
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 6
5. Require that disability insurance policies and self-insured health plans do 8
not make coverage decisions, determine reimbursement rates, establish incentive 9
programs, or design benefits in ways that discriminate against individuals because 10
of their age, disability, or expected length of life.
6. Establish essential health benefits in a way that takes into account the 12
health care needs of diverse segments of the population, including women, children, 13
persons with disabilities, and other groups.
7. Ensure that essential health benefits established under this subsection are 15
not subject to a coverage denial based on an insured's or plan participant's age, 16
expected length of life, present or predicted disability, degree of dependency on 17
medical care, or quality of life.
8. Require that disability insurance policies and self-insured health plans 19
cover emergency department services that are essential health benefits without 20
imposing any requirement to obtain prior authorization for those services and 21
without limiting coverage for services provided by an emergency services provider 22
that is not in the provider network of a policy or plan in a way that is more restrictive 23
than requirements or limitations that apply to emergency services provided by a 24
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 2
emergency department services that are essential health benefits provided by an 3
emergency department provider that is not in the provider network of the policy or 4
plan the same copayment amount or coinsurance rate that applies if those services 5
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 7
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 9
under this section and the coverage requirements are not identical, the disability 10
insurance policy or self-insured health plan shall provide coverage under whichever 11
subsection provides the insured or plan participant with more comprehensive 12
coverage of the medical condition, item, or service.