July 3, 2019 - Introduced by Senators Smith, Miller and Ringhand, cosponsored
by Representatives Kolste, Emerson, Anderson, Sargent, Considine,
Subeck, Ohnstad, Sinicki, C. Taylor, Vruwink, Shankland and Bowen.
Referred to Committee on Insurance, Financial Services, Government
Oversight and Courts.
SB313,1,2 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 an enrollee in a defined network plan or preferred provider plan
may receive services from a health care provider that is not in the plan's network.
Under the bill, a defined network plan or a preferred provider plan must annually
provide to enrollees a directory of providers and 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
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 not require the enrollee to pay 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 not require the enrollee to pay
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:
SB313,1 1Section 1. 609.07 of the statutes is created to read:
SB313,2,2 2609.07 Balance billing. (1) Definitions. In this section:
SB313,2,63 (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).
SB313,2,117 (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.
SB313,2,1512 (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.
SB313,3,5
1(2) Notice of network status. (a) A defined network plan or preferred provider
2plan shall provide, no less frequently than annually, a list of health care facilities
3that have agreed to facilitate the usage of providers that are in the plan's network.
4The list shall specify the percentage of providers at those health care facilities that
5are not in the plan's network.
SB313,3,116 (b) A defined network plan or preferred provider plan shall provide, no less
7frequently than annually, a directory of all providers that are in the plan's network
8and are under contract with health care facilities that are in the plan's network. In
9the directory, the defined network plan or preferred provider plan shall specify
10health care facilities that do not have contracts with providers in a particular
11specialty.
SB313,3,15 12(3) Disclosures. (a) A provider that is not in a defined network plan's or
13preferred provider plan's network and is under contract to provide services at a
14health care facility that is in the plan's network shall provide, in writing, to an
15enrollee of the defined network plan or preferred provider plan all of the following:
SB313,3,1716 1. That the enrollee may receive services from a provider that is not in the
17defined network plan's or preferred provider plan's network.
SB313,3,1918 2. A good faith estimate of the enrollee's financial responsibility for the services
19provided under subd. 1.
SB313,3,2120 3. That the enrollee is entitled to mediation under circumstances described in
21sub. (6).
SB313,3,2322 (b) In lieu of the provider providing the notice under par. (a), a health care
23facility may provide the notice described under par. (a).
SB313,4,2 24(4) Emergency services. (a) If an enrollee of a preferred provider plan that
25restricts or increases cost sharing for use of providers that are not in its network

1obtains emergency services from a provider not in the plan's network, the preferred
2provider plan shall do all of the following:
SB313,4,53 1. Allow the enrollee to obtain services from the provider until the enrollee can
4be transferred to a provider that is in the preferred provider plan's network in
5accordance with 42 USC 1395dd.
SB313,4,76 2. Reimburse the provider at the usual and customary rate or at a rate agreed
7to by the provider and the preferred provider plan.
SB313,4,108 3. Require the enrollee to pay an amount for the emergency services that is no
9more than the enrollee would have paid if the provider had been in the preferred
10provider plan's network.
SB313,4,1311 (b) If an enrollee of a defined network plan obtains emergency services from a
12provider that is not in the plan's network, the defined network plan shall do all of the
13following:
SB313,4,1514 1. Reimburse the provider at the usual and customary rate or at a rate agreed
15to by the provider and the defined network plan.
SB313,4,1816 2. Require the enrollee to pay an amount for the emergency services that is no
17more than the enrollee would have paid if the provider had been in the defined
18network plan's network.
SB313,4,23 19(5) Medically necessary services. If an enrollee of a defined network plan or
20a preferred provider plan that restricts or increases cost sharing for use of providers
21that are not in its network is unable to obtain medically necessary services within
22a reasonable time from a provider in the plan's network, the plan shall, upon the
23request of a provider that is in the plan's network, do all of the following:
SB313,4,2524 (a) Within a reasonable time, allow referral to a provider that is not within the
25plan's network.
SB313,5,5
1(b) Reimburse the provider that is not in the plan's network at the usual and
2customary rate or at a rate agreed to between the provider and the plan. The enrollee
3shall provide to the provider under this paragraph an assignment of benefits from
4the enrollee to the provider for any service, item, or supply that the provider provides
5to the enrollee.
SB313,5,86 (c) Require the enrollee to pay an amount for the medically necessary services
7that is no more than the enrollee would have paid if the provider had been in the
8preferred provider plan's or defined network plan's network.
SB313,5,11 9(6) Mediation. (a) Except as provided under par. (b), an enrollee of a defined
10network plan or preferred provider plan shall be entitled to request mediation to
11resolve a claim of a provider if all of the following apply:
SB313,5,1312 1. The provider is not in the network of the enrollee's defined network plan or
13preferred provider plan.
SB313,5,1614 2. The provider is under contract to provide services at a health care facility
15that is in the network of the enrollee's defined network plan or preferred provider
16plan.
SB313,5,1817 3. The enrollee is responsible for an amount, after copayments, deductibles,
18and coinsurance, that exceeds $500.
SB313,5,1919 (b) The enrollee is not entitled to request mediation if all of the following apply:
SB313,5,2020 1. The provider or health care facility provided the information under sub. (3).
SB313,5,2321 2. The amount that the enrollee is responsible for, after copayments,
22deductibles, and coinsurance, is less than the good faith estimate provided under
23sub. (3) (a) 2.
SB313,6,3
1(c) The defined network plan or preferred provider plan shall include in an
2explanation of benefits statement provided to an enrollee a notice that the enrollee
3may be entitled to request mediation as provided under this subsection.
SB313,6,5 4(7) Rules. The commissioner may promulgate rules to establish procedures for
5mediation under this section.
SB313,6,7 6(8) Conflicts. To the extent that this section conflicts with s. 609.10, 609.91,
7or 609.92, this section supersedes ss. 609.10, 609.91, and 609.92.
SB313,2 8Section 2. Initial applicability.
SB313,6,119 (1) (a) For plans or contracts containing provisions inconsistent with this act,
10the act first applies to plan or contract years beginning on January 1 of the year
11following the year in which this paragraph takes effect, except as provided in par. (b).
SB313,6,1612 (b) For plans or contracts that are affected by a collective bargaining agreement
13containing provisions inconsistent with this act, this act first applies to plan or
14contract years beginning on the effective date of this paragraph or on the day on
15which the collective bargaining agreement is newly established, extended, modified,
16or renewed, whichever is later.
SB313,3 17Section 3. Effective date.
SB313,6,1918 (1) This act takes effect on first day of the 7th month beginning after
19publication.
SB313,6,2020 (End)
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