Amendment ASA2-AB518

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1999 - 2000 LEGISLATURE

ASSEMBLY SUBSTITUTE AMENDMENT 2, TO 1999 ASSEMBLY BILL 518

October 26, 1999 - Offered by Representative Wasserman.

AB518-ASA2,1,11 An Act to repeal 609.15 (title) and (1) (intro.) and 609.22 (4) (a) 2.; to renumber 609.15 (1) (c), 609.15 (2) (c), 609.15 (2) (d) and 609.15 (2) (e); to renumber and amend 609.15 (1) (a), 609.15 (1) (b), 609.15 (2) (intro.), 609.15 (2) (a) and 609.15 (2) (b); to amend 40.51 (8), 40.51 (8m), 600.01 (2) (b), 601.42 (4), 609.05 (3), 609.22 (4) (a) 3., 609.39 and 609.655 (4) (b); to repeal and recreate 609.22 (4) (a) 1.; and to create 111.91 (2) (r), 601.31 (1) (Lp), 601.31 (1) (Lr), 609.39, 632.83 and 632.835 of the statutes; relating to: requiring insurers to establish internal grievance procedures, independent review of certain coverage determinations made by health benefit plans, obtaining the services of specialist providers, suing managed care plans and granting rule-making authority.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB518-ASA2, s. 1 Section 1. 40.51 (8) of the statutes is amended to read:

AB518-ASA2,2,5 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (5), 632.895 (5m) and (8) to (13) and 632.896.

AB518-ASA2, s. 2 Section 2. 40.51 (8m) of the statutes is amended to read:

AB518-ASA2,2,9 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 632.746 (1) to (8) and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855 and 632.895 (11) to (13).

AB518-ASA2, s. 3 Section 3. 111.91 (2) (r) of the statutes is created to read:

AB518-ASA2,2,13 111.91 (2) (r) The requirements related to internal grievance procedures under s. 632.83 and independent review of certain health benefit plan determinations under s. 632.835.

AB518-ASA2, s. 4 Section 4. 600.01 (2) (b) of the statutes is amended to read:

AB518-ASA2,2,16 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is not exempt from ss. 632.745 to 632.749, 632.83 or 632.835 or ch. 633 or 635.

AB518-ASA2, s. 5 Section 5. 601.31 (1) (Lp) of the statutes is created to read:

AB518-ASA2,2,19 601.31 (1) (Lp) For certifying as an independent review organization under s. 632.835, $400.

AB518-ASA2, s. 6 Section 6. 601.31 (1) (Lr) of the statutes is created to read:

AB518-ASA2,2,22 601.31 (1) (Lr) For each biennial recertification as an independent review organization under s. 632.835, $100.

AB518-ASA2, s. 7 Section 7. 601.42 (4) of the statutes is amended to read:

AB518-ASA2,3,10 601.42 (4) Replies. Any officer, manager or general agent of any insurer authorized to do or doing an insurance business in this state, any person controlling or having a contract under which the person has a right to control such an insurer, whether exclusively or otherwise, any person with executive authority over or in charge of any segment of such an insurer's affairs, any individual practice association or officer, director or manager of an individual practice association, any insurance agent or other person licensed under chs. 600 to 646, any provider of services under a continuing care contract, as defined in s. 647.01 (2), any independent review organization certified or recertified under s. 632.835 (4) or any health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or in other designated form, to any written inquiry from the commissioner requesting a reply.

AB518-ASA2, s. 8 Section 8. 609.05 (3) of the statutes is amended to read:

AB518-ASA2,3,16 609.05 (3) Except as provided in ss. 609.22 (4), 609.65 and 609.655, a limited service health organization, preferred provider plan or managed care plan may require an enrollee to obtain a referral from the primary provider designated under sub. (2) to another participating provider prior to obtaining health care services from that participating provider.

AB518-ASA2, s. 9 Section 9. 609.15 (title) and (1) (intro.) of the statutes are repealed.

AB518-ASA2, s. 10 Section 10. 609.15 (1) (a) of the statutes is renumbered 632.83 (2) (a) and amended to read:

AB518-ASA2,3,23 632.83 (2) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) (3) for the resolution of enrollees' insureds' grievances with the limited service health organization, preferred provider plan or managed care health benefit plan.

AB518-ASA2, s. 11 Section 11. 609.15 (1) (b) of the statutes is renumbered 632.83 (2) (b) and amended to read:

AB518-ASA2,4,2 632.83 (2) (b) Provide enrollees insureds with complete and understandable information describing the internal grievance procedure under par. (a).

AB518-ASA2, s. 12 Section 12. 609.15 (1) (c) of the statutes is renumbered 632.83 (2) (c).

AB518-ASA2, s. 13 Section 13. 609.15 (2) (intro.) of the statutes is renumbered 632.83 (3) (intro.) and amended to read:

AB518-ASA2,4,7 632.83 (3) (intro.) The internal grievance procedure established under sub. (1) (2) (a) shall include all of the following elements:

AB518-ASA2, s. 14 Section 14. 609.15 (2) (a) of the statutes is renumbered 632.83 (3) (a) and amended to read:

AB518-ASA2,4,11 632.83 (3) (a) The opportunity for an enrollee insured to submit a written grievance in any form.

AB518-ASA2, s. 15 Section 15. 609.15 (2) (b) of the statutes is renumbered 632.83 (3) (b) and amended to read:

AB518-ASA2,4,17 632.83 (3) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrollee insured other than the grievant, if an enrollee insured is available to serve on the grievance panel.

AB518-ASA2, s. 16 Section 16. 609.15 (2) (c) of the statutes is renumbered 632.83 (3) (c).

AB518-ASA2, s. 17 Section 17. 609.15 (2) (d) of the statutes is renumbered 632.83 (3) (d).

AB518-ASA2, s. 18 Section 18. 609.15 (2) (e) of the statutes is renumbered 632.83 (3) (e).

AB518-ASA2, s. 19 Section 19. 609.22 (4) (a) 1. of the statutes is repealed and recreated to read:

AB518-ASA2,5,2 609.22 (4) (a) 1. A managed care plan may not require an enrollee of the managed care plan to obtain a referral for coverage of services provided by a participating provider who is a physician licensed under ch. 448 and who specializes in a particular type of medical practice, regardless of whether the participating provider is the enrollee's primary provider.

AB518-ASA2, s. 20 Section 20. 609.22 (4) (a) 2. of the statutes is repealed.

AB518-ASA2, s. 21 Section 21. 609.22 (4) (a) 3. of the statutes is amended to read:

AB518-ASA2,5,8 609.22 (4) (a) 3. A managed care plan must include information regarding referral procedures the requirement under subd. 1. in policies or certificates provided to enrollees and must provide such information to an enrollee or prospective enrollee upon request.

AB518-ASA2, s. 22 Section 22. 609.39 of the statutes is created to read:

AB518-ASA2,5,11 609.39 Right to sue. A person may bring an action in tort against a managed care plan for a bad faith denial of coverage.

AB518-ASA2, s. 23 Section 23. 609.39 of the statutes, as created by 1999 Wisconsin Act .... (this act), is amended to read:

AB518-ASA2,5,17 609.39 Right to sue. A person may bring an action in tort against a managed care plan for a bad faith denial of coverage, unless the person has requested and obtained an independent review of the managed care plan's denial of coverage, as provided under s. 632.835.

AB518-ASA2, s. 24 Section 24. 609.655 (4) (b) of the statutes is amended to read:

AB518-ASA2,6,2 609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the managed care plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the managed care plan's internal grievance procedure established under s. 609.15 632.83.

AB518-ASA2, s. 25 Section 25. 632.83 of the statutes is created to read:

AB518-ASA2,6,8 632.83 Internal grievance procedure. (1) In this section, "health benefit plan" has the meaning given in s. 632.745 (11), except that "health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 2., 3., 5. and 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.