LRBa0045/1
TJD:cjs
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
Zamarripa.
AB1-ASA1-AA2,1,11 At the locations indicated, amend the substitute amendment as follows:
AB1-ASA1-AA2,1,4 21. Page 1, line 4: after “plans" insert “, prohibiting certain benefit limits in
3health benefit plans, essential health benefits, and requiring the exercise of
4rule-making authority".
AB1-ASA1-AA2,1,5 52. Page 2, line 5: before “632.885" insert “632.883,".
AB1-ASA1-AA2,1,6 63. Page 2, line 11: before “632.885" insert “632.883,".
AB1-ASA1-AA2,1,7 74. Page 3, line 6: before “632.885" insert “632.883,".
AB1-ASA1-AA2,1,8 85. Page 3, line 11: before “632.885" insert “632.883,".
AB1-ASA1-AA2,1,9 96. Page 3, line 19: before “632.885" insert “632.883,".
AB1-ASA1-AA2,1,10 107. Page 3, line 21: after that line insert:
AB1-ASA1-AA2,1,11 11 Section 5s. 609.713 of the statutes is created to read:
AB1-ASA1-AA2,2,2
1609.713 Essential health benefits. Defined network plans and preferred
2provider plans are subject to s. 632.895 (14m).
AB1-ASA1-AA2,5t 3Section 5t. 609.845 of the statutes is created to read:
AB1-ASA1-AA2,2,5 4609.845 Lifetime and annual limits. Limited service health organizations,
5preferred provider plans, and defined network plans are subject to s. 632.883.”.
AB1-ASA1-AA2,2,6 68. Page 6, line 12: after that line insert:
AB1-ASA1-AA2,2,7 7 Section 7m. 632.883 of the statutes is created to read:
AB1-ASA1-AA2,2,9 8632.883 Lifetime and annual limits; prohibiting discrimination based
9on preexisting conditions.
(1) In this section:
AB1-ASA1-AA2,2,1010 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).
AB1-ASA1-AA2,2,1111 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB1-ASA1-AA2,2,13 12(2) An individual or group health benefit plan or a self-insured health plan
13may not establish any of the following:
AB1-ASA1-AA2,2,1514 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
15of an enrollee under the plan.
AB1-ASA1-AA2,2,1716 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent
17of an enrollee under the plan.
AB1-ASA1-AA2,2,23 18(3) For the purpose of setting rates or premiums for coverage under a group or
19individual heath benefit plan or a self-insured health plan and for the purpose of
20setting any deductibles, copayments, or coinsurance under a group or individual
21health benefit plan or a self-insured health plan, the plan may not consider whether
22an individual, including a dependent, who would be covered under the plan has a
23preexisting condition.
AB1-ASA1-AA2,7s 24Section 7s. 632.895 (14m) of the statutes is created to read:
AB1-ASA1-AA2,3,2
1632.895 (14m) Essential health benefits. (a) In this subsection,
2“self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB1-ASA1-AA2,3,63 (b) On a date specified by the commissioner, by rule, every disability insurance
4policy, except as provided in par. (g), and every self-insured health plan shall provide
5coverage for essential health benefits as determined by the commissioner, by rule,
6subject to par. (c).
AB1-ASA1-AA2,3,87 (c) In determining the essential health benefits for which coverage is required
8under par. (b), the commissioner shall do all of the following:
AB1-ASA1-AA2,3,109 1. Include benefits, items, and services in, at least, all of the following
10categories:
AB1-ASA1-AA2,3,1111 a. Ambulatory patient services.
AB1-ASA1-AA2,3,1212 b. Emergency services.
AB1-ASA1-AA2,3,1313 c. Hospitalization.
AB1-ASA1-AA2,3,1414 d. Maternity and newborn care.
AB1-ASA1-AA2,3,1615 e. Mental health and substance use disorder services, including behavioral
16health treatment.
AB1-ASA1-AA2,3,1717 f. Prescription drugs.
AB1-ASA1-AA2,3,1818 g. Rehabilitative and habilitative services and devices.
AB1-ASA1-AA2,3,1919 h. Laboratory services.
AB1-ASA1-AA2,3,2020 i. Preventive and wellness services and chronic disease management.
AB1-ASA1-AA2,3,2121 j. Pediatric services, including oral and vision care.
AB1-ASA1-AA2,4,222 2. Conduct a survey of employer-sponsored coverage to determine benefits
23typically covered by employers and ensure that the scope of essential health benefits
24for which coverage is required under this subsection is equal to the scope of benefits

1covered under a typical disability insurance policy offered by an employer to its
2employees.
AB1-ASA1-AA2,4,43 3. Ensure that essential health benefits reflect a balance among the categories
4described in subd. 1. such that benefits are not unduly weighted toward one category.
AB1-ASA1-AA2,4,65 4. Ensure that essential health benefit coverage is provided with no or limited
6cost-sharing requirements.
AB1-ASA1-AA2,4,107 5. Require that disability insurance policies and self-insured health plans do
8not make coverage decisions, determine reimbursement rates, establish incentive
9programs, or design benefits in ways that discriminate against individuals because
10of their age, disability, or expected length of life.
AB1-ASA1-AA2,4,1311 6. Establish essential health benefits in a way that takes into account the
12health care needs of diverse segments of the population, including women, children,
13persons with disabilities, and other groups.
AB1-ASA1-AA2,4,1714 7. Ensure that essential health benefits established under this subsection are
15not subject to a coverage denial based on an insured's or plan participant's age,
16expected length of life, present or predicted disability, degree of dependency on
17medical care, or quality of life.
AB1-ASA1-AA2,4,2418 8. Require that disability insurance policies and self-insured health plans
19cover emergency department services that are essential health benefits without
20imposing any requirement to obtain prior authorization for those services and
21without limiting coverage for services provided by an emergency services provider
22that is not in the provider network of a policy or plan in a way that is more restrictive
23than requirements or limitations that apply to emergency services provided by a
24provider that is in the provider network of the policy or plan.
AB1-ASA1-AA2,5,5
19. Require a disability insurance policy or self-insured health plan to apply to
2emergency department services that are essential health benefits provided by an
3emergency department provider that is not in the provider network of the policy or
4plan the same copayment amount or coinsurance rate that applies if those services
5are provided by a provider that is in the provider network of the policy or plan.
AB1-ASA1-AA2,5,76 (d) The commissioner shall periodically update, by rule, the essential health
7benefits under this subsection to address any gaps in access to coverage.
AB1-ASA1-AA2,5,128 (e) If an essential health benefit is also subject to mandated coverage elsewhere
9under this section and the coverage requirements are not identical, the disability
10insurance policy or self-insured health plan shall provide coverage under whichever
11subsection provides the insured or plan participant with more comprehensive
12coverage of the medical condition, item, or service.
AB1-ASA1-AA2,5,1613 (f) Nothing in this subsection or rules promulgated under this subsection
14prohibits a disability insurance policy or a self-insured health plan from providing
15benefits in excess of the essential health benefit coverage required under this
16subsection.
AB1-ASA1-AA2,5,1817 (g) This subsection does not apply to any disability insurance policy that is
18described in s. 632.745 (11) (b) 1. to 12.
AB1-ASA1-AA2,8m 19Section 8m. Initial applicability.
AB1-ASA1-AA2,5,23 20(1) Lifetime and annual limits. For policies and plans containing provisions
21inconsistent with s. 632.883, the treatment of s. 632.883 first applies to plan years
22beginning on January 1 of the year following the year in which this subsection takes
23effect.”.

This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
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