LRBb1287/1
PJK&RPN:cmh:kjf
1999 - 2000 LEGISLATURE
ASSEMBLY AMENDMENT 7,
TO ASSEMBLY SUBSTITUTE AMENDMENT 1,
TO 1999 ASSEMBLY BILL 133
June 29, 1999 - Offered by Representative Wasserman.
AB133-ASA1-AA7,1,84
609.05
(3) Except as provided in ss.
609.22 (4), 609.65 and 609.655, a limited
5service health organization, preferred provider plan or managed care plan may
6require an enrollee to obtain a referral from the primary provider designated under
7sub. (2) to another participating provider prior to obtaining health care services from
8that participating provider.
AB133-ASA1-AA7,2,3
10609.16 Appeals. (1) After using the procedure under s. 609.15, a grievant may
11appeal the decision of a managed care plan under s. 609.15. The appeal shall be made
12to a physician who is licensed under ch. 448, who is not a participating provider of
1the managed care plan and who specializes in the type of medical practice to which
2the grievance relates. The decision of the physician hearing the appeal is binding on
3the grievant and the managed care plan.
AB133-ASA1-AA7,2,6
4(2) A managed care plan must include information regarding the appeal
5procedure in policies or certificates provided to enrollees and must provide such
6information to an enrollee or prospective enrollee upon request.
AB133-ASA1-AA7,2,9
7(3) The commissioner shall promulgate rules for the appeal procedure under
8this section, including rules related to how an enrollee requests an appeal and how
9the physician hearing the appeal is selected.
AB133-ASA1-AA7,2,1612
609.22
(4) (a) 1. A managed care plan may not require an enrollee of the
13managed care plan to obtain a referral for coverage of services provided by a
14participating provider who is a physician licensed under ch. 448 and who specializes
15in a particular type of medical practice, regardless of whether the participating
16provider is the enrollee's primary provider.
AB133-ASA1-AA7,2,2219
609.22
(4) (a) 3. A managed care plan must include information regarding
20referral procedures the requirement under subd. 1. in policies or certificates
21provided to enrollees and must provide such information to an enrollee or prospective
22enrollee upon request.
AB133-ASA1-AA7,2,25
24609.39 Right to sue. Any person may bring an action in tort for negligence,
25including an action for medical malpractice, against a managed care plan.".
AB133-ASA1-AA7,3,2
2"
(3g) Specialist providers under managed care plans.
AB133-ASA1-AA7,3,8
3(a) Except as provided in paragraph (b), if a policy or certificate that is affected
4by the treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes
5contains terms or provisions that are inconsistent with the treatment of sections
6609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes, the treatment of sections
7609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes first applies to that policy or
8certificate upon renewal.
AB133-ASA1-AA7,3,13
9(b) The treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the
10statutes first applies to policies or group certificates covering employes who are
11affected by a collective bargaining agreement containing provisions that are
12inconsistent with the treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3.
13of the statutes that are issued or renewed on the earlier of the following:
AB133-ASA1-AA7,3,14
141. The day on which the collective bargaining agreement expires.
AB133-ASA1-AA7,3,16
152. The day on which the collective bargaining agreement is extended, modified
16or renewed.
AB133-ASA1-AA7,3,17
17(3h) Appeals of decisions of managed care plans.
AB133-ASA1-AA7,3,19
18(a) The treatment of section 609.16 (1) of the statutes first applies to grievances
19arising on September 1, 2000.
AB133-ASA1-AA7,3,21
20(b) The treatment of section 609.16 (2) of the statutes first applies to policies
21issued or renewed on September 1, 2000.
AB133-ASA1-AA7,3,24
22(3i) Lawsuits against managed care plans. The treatment of section 609.39 of
23the statutes first applies to injuries or deaths occurring on the effective date of this
24subsection.".
AB133-ASA1-AA7,4,3
2"
(2g) Appeals of decisions of managed care plans. The treatment of section
3609.16 (1) and (2) of the statutes takes effect on September 1, 2000.".
