2. A good faith estimate of the enrollee's financial responsibility for the services 19
provided under subd. 1.
3. That the enrollee is entitled to mediation under circumstances described in 21
(b) In lieu of the provider providing the notice under par. (a), a health care 23
facility may provide the notice described under par. (a).
24(4) Emergency services
. (a) If an enrollee of a preferred provider plan that 25
restricts or increases cost sharing for use of providers that are not in its network
obtains emergency services from a provider not in the plan's network, the preferred 2
provider plan shall do all of the following:
1. Allow the enrollee to obtain services from the provider until the enrollee can 4
be transferred to a provider that is in the preferred provider plan's network in 5
accordance with 42 USC 1395dd
2. Reimburse the provider at the usual and customary rate or at a rate agreed 7
to by the provider and the preferred provider plan.
3. Require the enrollee to pay an amount for the emergency services that is no 9
more than the enrollee would have paid if the provider had been in the preferred 10
provider plan's network.
(b) If an enrollee of a defined network plan obtains emergency services from a 12
provider that is not in the plan's network, the defined network plan shall do all of the 13
1. Reimburse the provider at the usual and customary rate or at a rate agreed 15
to by the provider and the defined network plan.
2. Require the enrollee to pay an amount for the emergency services that is no 17
more than the enrollee would have paid if the provider had been in the defined 18
network plan's network.
19(5) Medically necessary services
. If an enrollee of a defined network plan or 20
a preferred provider plan that restricts or increases cost sharing for use of providers 21
that are not in its network is unable to obtain medically necessary services within 22
a reasonable time from a provider in the plan's network, the plan shall, upon the 23
request of a provider that is in the plan's network, do all of the following:
(a) Within a reasonable time, allow referral to a provider that is not within the 25
(b) Reimburse the provider that is not in the plan's network at the usual and 2
customary rate or at a rate agreed to between the provider and the plan. The enrollee 3
shall provide to the provider under this paragraph an assignment of benefits from 4
the enrollee to the provider for any service, item, or supply that the provider provides 5
to the enrollee.
(c) Require the enrollee to pay an amount for the medically necessary services 7
that is no more than the enrollee would have paid if the provider had been in the 8
preferred provider plan's or defined network plan's network.
. (a) Except as provided under par. (b), an enrollee of a defined 10
network plan or preferred provider plan shall be entitled to request mediation to 11
resolve a claim of a provider if all of the following apply:
1. The provider is not in the network of the enrollee's defined network plan or 13
preferred provider plan.
2. The provider is under contract to provide services at a health care facility 15
that is in the network of the enrollee's defined network plan or preferred provider 16
3. The enrollee is responsible for an amount, after copayments, deductibles, 18
and coinsurance, that exceeds $500.
(b) The enrollee is not entitled to request mediation if all of the following apply:
1. The provider or health care facility provided the information under sub. (3).
2. The amount that the enrollee is responsible for, after copayments, 22
deductibles, and coinsurance, is less than the good faith estimate provided under 23
sub. (3) (a) 2.
(c) The defined network plan or preferred provider plan shall include in an 2
explanation of benefits statement provided to an enrollee a notice that the enrollee 3
may be entitled to request mediation as provided under this subsection.
. The commissioner may promulgate rules to establish procedures for 5
mediation under this section.
. To the extent that this section conflicts with s. 609.10, 609.91, 7
or 609.92, this section supersedes ss. 609.10, 609.91, and 609.92.
(1) (a) For plans or contracts containing provisions inconsistent with this act, 10
the act first applies to plan or contract years beginning on January 1 of the year 11
following the year in which this paragraph takes effect, except as provided in par. (b).
(b) For plans or contracts that are affected by a collective bargaining agreement 13
containing provisions inconsistent with this act, this act first applies to plan or 14
contract years beginning on the effective date of this paragraph or on the day on 15
which the collective bargaining agreement is newly established, extended, modified, 16
or renewed, whichever is later.
This act takes effect on first day of the 7th month beginning after 19