LRB-0005/1
AJM:klm
2017 - 2018 LEGISLATURE
February 7, 2018 - Introduced by Senators Vinehout, Carpenter and Risser,
cosponsored by Representatives Sargent, Kolste, Vruwink, Pope, Subeck,
Berceau, Crowley, Mursau and Bernier. Referred to Committee on
Insurance, Financial Services, Constitution and Federalism.
SB778,1,2 1An Act to create 609.07 of the statutes; relating to: billing practices for certain
2health care providers and granting rule-making authority.
Analysis by the Legislative Reference Bureau
This bill creates disclosure, notice, billing, and mediation requirements for the
situation in which a patient may receive services from a health care provider that is
not in the network of the patient's defined network plan or preferred provider plan.
Under the bill, a defined network plan or a preferred provider plan must annually
provide to members of the plan a directory of providers that are in its network. The
defined network plan or preferred provider plan must also provide its members a list
of health care facilities that are in its network.
The bill also requires that a provider who is not in the network of the enrollee's
defined network plan or preferred provider plan but is providing a service at an
in-network health care facility must disclose that information to the enrollee,
provide the enrollee a good-faith estimate of the cost of services the enrollee may be
responsible for, and inform the enrollee of the availability of mediation to settle
disputes over the cost of services. In particular, the enrollee is entitled to mediation
for a claim if the amount that the enrollee is financially responsible for, after
copayments, deductibles, and coinsurance, is more than $500. The enrollee is not
entitled to mediation if the out-of-network provider provides the required disclosure
and the amount the enrollee is financially responsible for is less than the good-faith
estimate provided by the provider. The health care facility may opt to provide the
notice for the provider.
Under the bill, if an enrollee of a defined network plan or preferred provider
plan requires medically necessary services that are not available from an

in-network provider within a reasonable time, then the plan must provide an
opportunity for referral to an out-of-network provider. The plan must reimburse the
out-of-network provider at the usual and customary rate or at a rate agreed to
between the provider and the plan and may only require that the enrollee pay no
more than the enrollee would have paid had the provider been in the plan's network.
The bill requires the enrollee to provide the out-of-network provider an assignment
of benefits for any service, item or supply provided by that provider.
Similarly, under the bill, if an enrollee of a defined network plan or preferred
provider plan receives emergency services from an out-of-network provider, then
the plan must reimburse the provider at the usual and customary rate or at a rate
agreed to between the provider and the plan and may only require the enrollee to pay
no more than the enrollee would have paid if the provider was in the plan's network.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB778,1 1Section 1. 609.07 of the statutes is created to read:
SB778,2,2 2609.07 Balance billing. (1) Definitions. In this section:
SB778,2,63 (a) “Assignment of benefits” means a written instrument signed by an insured
4or the authorized representative of an insured that assigns to a provider the
5insured's claim for payment, reimbursement, or benefits under a disability
6insurance policy as defined in s. 632.895 (1) (a).
SB778,2,117 (b) “Emergency services” means those services required to treat and stabilize
8an emergency medical condition in accordance with 42 USC 1395dd and services
9originating in a hospital emergency department, a freestanding emergency
10department, or a similar facility following treatment or stabilization of an emergency
11medical condition.
SB778,2,1512 (c) “Network” means the providers that are under contract with a defined
13network plan or preferred provider plan to provide services to enrollees at an agreed
14price, for which the provider receives reimbursement in accordance with the
15contract.
SB778,3,6
1(2) Notice of network status. (a) A a defined network plan or preferred
2provider plan shall provide, no less frequently than annually, a list of hospitals that
3have agreed to facilitate the usage of providers that are in the defined network plan's
4or preferred provider plan's network. The list shall specify the percentage of
5providers at those hospitals that are not in the defined network plan's or preferred
6provider plan's network.
SB778,3,137 (b) A defined network plan or preferred provider plan shall provide, no less
8frequently than annually, a directory of all providers that are in the defined network
9plan's or preferred provider plan's network that are under contract with health care
10facilities that are in the defined network plan's or preferred provider plan's network.
11In the directory, the defined network plan or preferred provider plan shall specify
12health care facilities that do not have contracts with providers in a particular
13specialty.
SB778,3,18 14(3) Disclosures. (a) A provider that is not in a defined network plan's or
15preferred provider plan's network and is under contract to provide services at a
16health care facility that is in the defined network plan's or preferred provider plan's
17network shall provide, in writing, to an enrollee of the defined network plan or
18preferred provider plan all of the following:
SB778,3,2019 1. That the enrollee may receive services from a provider that is not in their
20defined network plan's or preferred provider plan's network.
SB778,3,2221 2. A good faith estimate of the enrollee's financial responsibility for the services
22provided under subd. 1.
SB778,3,2423 3. That the enrollee is entitled to mediation under circumstances described in
24sub. (6).
SB778,4,2
1(b) In lieu of the provider providing the notice under par. (a), a health care
2facility may provide the notice described under par. (a).
SB778,4,6 3(4) Emergency services. (a) If an enrollee of a preferred provider plan that
4restricts or increases cost sharing for use of providers that are not in its network
5obtains emergency services from a provider not in the preferred provider plan's
6network, the preferred provider plan shall do all of the following:
SB778,4,97 1. Allow the enrollee to obtain services from the provider until the enrollee can
8be transferred to a provider that is in the preferred provider plan's network in
9accordance with 42 USC 1395dd.
SB778,4,1110 2. Reimburse the provider at the usual and custom rate or at a rate agreed to
11by the provider and the preferred provider plan.
SB778,4,1412 3. Require the enrollee to pay an amount for the emergency services that is no
13more than the enrollee would have paid if the provider had been in the preferred
14provider plan's network.
SB778,4,1715 (b) If an enrollee of a defined network plan obtains emergency services from a
16provider that is not in the defined network plan's network, the defined network plan
17shall do all of the following:
SB778,4,1918 1. Reimburse the provider at the usual and customary rate or at a rate agreed
19to by the provider and the defined network plan.
SB778,4,2220 2. Require the enrollee to pay an amount for the emergency services that is no
21more than the enrollee would have paid if the provider had been in the defined
22network plan's network.
SB778,5,2 23(5) Medically necessary services. If an enrollee of a defined network plan or
24a preferred provider plan that restricts or increases cost sharing for use of providers
25that are not in its network is unable to obtain medically necessary services within

1a reasonable time from a provider in the plan's network, the plan shall, upon the
2request of a provider that is in the plan's network, do all of the following:
SB778,5,43 (a) Within a reasonable time, allow referral to a provider that is not within the
4preferred provider plan's or defined network plan's network.
SB778,5,95 (b) Reimburse the provider that is not in the preferred provider plan's or
6defined network plan's network at the usual and customary rate or at a rate agreed
7to between the provider and the plan. The enrollee shall provide to the provider
8under this paragraph an assignment of benefits from the enrollee to the provider for
9any service, item, or supply that the provider provides to the enrollee.
SB778,5,1210 (c) Require the enrollee to pay an amount for the medically necessary services
11that is no more than the enrollee would have paid if the provider had been in the
12preferred provider plan's or defined network plan's network.
SB778,5,15 13(6) Mediation. (a) Except as provided under par. (b), an enrollee of a defined
14network plan or preferred provider plan shall be entitled to request mediation to
15resolve a claim if all of the following apply:
SB778,5,1716 1. The provider is not in the network of the enrollee's defined network plan or
17preferred provider plan.
SB778,5,2018 2. The provider is under contract to provide services at a health care facility
19that is generally in the network of the enrollee's defined network plan or preferred
20provider plan.
SB778,5,2221 3. The enrollee is responsible for an amount, after copayments, deductibles,
22and coinsurance, that exceeds $500.
SB778,5,2323 (b) The enrollee is not entitled to request mediation if all of the following apply:
SB778,5,2424 1. The provider or health care facility provided the notice under sub. (2).
SB778,6,3
12. The amount that the enrollee is responsible for, after copayments,
2deductibles, and coinsurance, is less than the good faith estimate provided under
3sub. (3) (a) 2.
SB778,6,64 (c) The defined network plan or preferred provider plan shall include in an
5explanation of benefits statement provided to an enrollee a notice that the enrollee
6may be entitled to request mediation as provided under this subsection.
SB778,6,8 7(7) Rules. The commissioner may promulgate rules to establish procedures for
8mediation under this section.
SB778,6,10 9(8) Conflicts. To the extent that this section conflicts with s. 609.10, 609.91,
10or 609.92, this section supersedes ss. 609.10, 609.91, and 609.92.
SB778,2 11Section 2. Initial applicability.
SB778,6,1512 (1) (a) For plans or contracts containing provisions inconsistent with this act,
13the act first applies to plan or contract years beginning on January 1 of the year
14following the year in which this paragraph takes effect, except as provided in
15paragraph (b).
SB778,6,2016 (b) For plans or contracts that are affected by a collective bargaining agreement
17containing provisions inconsistent with this act, this act first applies to plan or
18contract years beginning on the effective date of this paragraph or on the day on
19which the collective bargaining agreement is newly established, extended, modified,
20or renewed, whichever is later.
SB778,3 21Section 3. Effective date.
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