AB768-ASA1,423,97
(b) If a licensee or an applicant for any license is not an individual, the
8department shall disclose the person's federal employer identification number to the
9department of revenue for the purpose of requesting certifications under s. 73.0301.
AB768-ASA1, s. 566bp
10Section 566bp. 563.80 of the statutes is renumbered 563.80 (intro.) and
11amended to read:
AB768-ASA1,423,14
12563.80 Gross receipts tax. (intro.) An occupational tax is imposed on those
13gross receipts of any licensed organization which are derived from the conduct of
14bingo, in the
amount of 2% of such gross receipts
following amounts:
AB768-ASA1,423,16
15(1) One percent of the first $30,000 in gross receipts received by a licensed
16organization during a year.
AB768-ASA1,423,1918
563.80
(2) Two percent of the gross receipts received by a licensed organization
19during a year that exceed $30,000.
AB768-ASA1,423,2422
565.05
(1) (intro.) No employe
of in the
lottery division of the department
who
23performs any duty related to the state lottery or the executive assistant or the
24secretary or deputy secretary of revenue may do any of the following:
AB768-ASA1,424,73
565.05
(1) (a) Have a direct or indirect interest in, or be employed by, any
4vendor while serving as an employe in the
lottery division of the department
and
5performing any duty related to the state lottery or as the executive assistant or as
6secretary or deputy secretary of revenue or for 2 years following the person's
7termination of service.
AB768-ASA1,424,1410
565.17
(5) (a) No employe
of in the
lottery division of the department
who
11performs any duty related to the state lottery or the executive assistant or the
12secretary or deputy secretary of revenue and no member of such a person's
13immediate family, as defined in s. 19.42 (7), may purchase a lottery ticket or lottery
14share.
AB768-ASA1,424,2116
601.42
(1g) (d) Statements, reports, answers to questionnaires or other
17information, or reports, audits or certification from a certified public accountant or
18an actuary approved by the commissioner, relating to the extent liabilities of a health
19maintenance organization insurer are or will be
covered liabilities, as defined in s.
20609.01 (1) liabilities for health care costs for which an enrollee or policyholder of the
21health maintenance organization is not liable to any person under s. 609.91.
AB768-ASA1, s. 566cce
22Section 566cce. Chapter 609 (title) of the statutes is repealed and recreated
23to read:
AB768-ASA1,424,2524
Chapter 609
25
managed care plans
AB768-ASA1,425,43
609.01
(1c) "Emergency medical condition" has the meaning given in s. 632.85
4(1) (a).
AB768-ASA1,425,86
609.01
(1d) "Enrollee" means, with respect to a managed care plan, preferred
7provider plan or limited service health organization, a person who is entitled to
8receive health care services under the plan.
AB768-ASA1,425,1110
609.01
(1g) (a) Except as provided in par. (b), "health benefit plan" means any
11hospital or medical policy or certificate.
AB768-ASA1,425,1212
(b) "Health benefit plan" does not include any of the following:
AB768-ASA1,425,1413
1. Coverage that is only accident or disability income insurance, or any
14combination of the 2 types.
AB768-ASA1,425,1515
2. Coverage issued as a supplement to liability insurance.
AB768-ASA1,425,1716
3. Liability insurance, including general liability insurance and automobile
17liability insurance.
AB768-ASA1,425,1818
4. Worker's compensation or similar insurance.
AB768-ASA1,425,1919
5. Automobile medical payment insurance.
AB768-ASA1,425,2020
6. Credit-only insurance.
AB768-ASA1,425,2121
7. Coverage for on-site medical clinics.
AB768-ASA1,425,2422
8. Other similar insurance coverage, as specified in regulations issued by the
23federal department of health and human services, under which benefits for medical
24care are secondary or incidental to other insurance benefits.
AB768-ASA1,426,6
19. If provided under a separate policy, certificate or contract of insurance, or if
2otherwise not an integral part of the policy, certificate or contract of insurance:
3limited-scope dental or vision benefits; benefits for long-term care, nursing home
4care, home health care, community-based care, or any combination of those benefits;
5and such other similar, limited benefits as are specified in regulations issued by the
6federal department of health and human services under section 2791 of P.L.
104-191.
AB768-ASA1,426,87
10. Hospital indemnity or other fixed indemnity insurance or coverage only for
8a specified disease or illness, if all of the following apply:
AB768-ASA1,426,109
a. The benefits are provided under a separate policy, certificate or contract of
10insurance.
AB768-ASA1,426,1311
b. There is no coordination between the provision of such benefits and any
12exclusion of benefits under any group health plan maintained by the same plan
13sponsor.
AB768-ASA1,426,1614
c. Such benefits are paid with respect to an event without regard to whether
15benefits are provided with respect to such an event under any group health plan
16maintained by the same plan sponsor.
AB768-ASA1,426,1717
11. Other insurance exempted by rule of the commissioner.
AB768-ASA1,426,2419
609.01
(2) "Health maintenance organization" means a health care plan
20offered by an organization established under ch. 185, 611, 613 or 614 or issued a
21certificate of authority under ch. 618 that makes available to its
enrolled
22participants enrollees, in consideration for predetermined periodic fixed payments,
23comprehensive health care services performed by providers
selected by the
24organization participating in the plan.
AB768-ASA1,427,6
1609.01
(3) "Limited service health organization" means a health care plan
2offered by an organization established under ch. 185, 611, 613 or 614 or issued a
3certificate of authority under ch. 618 that makes available to its
enrolled
4participants enrollees, in consideration for predetermined periodic fixed payments,
5a limited range of health care services performed by providers
selected by the
6organization participating in the plan.
AB768-ASA1,427,128
609.01
(3c) "Managed care plan" means a health benefit plan that requires an
9enrollee of the health benefit plan, or creates incentives, including financial
10incentives, for an enrollee of the health benefit plan, to use providers that are
11managed, owned, under contract with or employed by the insurer offering the health
12benefit plan.
AB768-ASA1,427,1814
609.01
(3m) "Participating" means, with respect to a physician or other
15provider, under contract with a managed care plan, preferred provider plan or
16limited service health organization to provide health care services, items or supplies
17to enrollees of the managed care plan, preferred provider plan or limited service
18health organization.
AB768-ASA1,427,2020
609.01
(3r) "Physician" has the meaning given in s. 448.01 (5).
AB768-ASA1,428,222
609.01
(4) "Preferred provider plan" means a health care plan offered by an
23organization established under ch. 185, 611, 613 or 614 or issued a certificate of
24authority under ch. 618 that makes available to its
enrolled participants enrollees,
25for consideration other than predetermined periodic fixed payments, either
1comprehensive health care services or a limited range of health care services
2performed by providers
selected by the organization
participating in the plan.
AB768-ASA1,428,54
609.01
(4m) "Primary care physician" means a physician specializing in family
5medical practice, general internal medicine or pediatrics.
AB768-ASA1,428,107
609.01
(5) "Primary provider" means a participating primary care physician,
8or other participating provider authorized by the managed care plan, preferred
9provider plan or limited service health organization to serve as a primary provider,
10who coordinates and may provide ongoing care to an enrollee.
AB768-ASA1,428,1312
609.01
(6) "Specialist physician" means a physician who is not a primary care
13physician.
AB768-ASA1,428,1815
609.05
(1) Except as provided in subs. (2) and (3), a
health maintenance
16organization, limited service health organization
or
, preferred provider plan
or 17managed care plan shall permit its
enrolled participants enrollees to choose freely
18among
selected participating providers.
AB768-ASA1,428,2320
609.05
(2) A health care plan under sub. (1) Subject to s. 609.22 (4), a limited
21service health organization, preferred provider plan or managed care plan may
22require an
enrolled participant enrollee to designate a primary provider and to
23obtain health care services from the primary provider when reasonably possible.
AB768-ASA1,429,6
1609.05
(3) Except as provided in ss. 609.65 and 609.655, a
health care plan
2under sub. (1) limited service health organization, preferred provider plan or
3managed care plan may require an
enrolled participant enrollee to obtain a referral
4from the primary provider designated under sub. (2) to another
selected 5participating provider prior to obtaining health care services from
the other selected 6that participating provider.
AB768-ASA1,429,138
609.10
(1) (a) Except as provided in subs. (2) to (4), an employer that offers any
9of its employes a health maintenance organization or a preferred provider plan that
10provides comprehensive health care services shall also offer the employes a standard
11plan, as provided in pars. (b) and (c), that provides at least substantially equivalent
12coverage of health care expenses
and that is not a health maintenance organization
13or a preferred provider plan.
AB768-ASA1,429,1715
609.15
(1) (intro.) Each
health maintenance organization, limited service
16health organization
and, preferred provider plan
and managed care plan shall do all
17of the following:
AB768-ASA1,429,2219
609.15
(1) (a) Establish and use an internal grievance procedure that is
20approved by the commissioner and that complies with sub. (2) for the resolution of
21enrolled participants' enrollees' grievances with the
health care limited service
22health organization, preferred provider plan or managed care plan.
AB768-ASA1,430,3
1609.15
(1) (b) Provide
enrolled participants enrollees with complete and
2understandable information describing the internal grievance procedure under par.
3(a).
AB768-ASA1,430,65
609.15
(2) (a) The opportunity for an
enrolled participant enrollee to submit
6a written grievance in any form.
AB768-ASA1,430,128
609.15
(2) (b) Establishment of a grievance panel for the investigation of each
9grievance submitted under par. (a), consisting of at least one individual authorized
10to take corrective action on the grievance and at least one
enrolled participant 11enrollee other than the grievant, if an
enrolled participant enrollee is available to
12serve on the grievance panel.
AB768-ASA1,430,19
14609.17 Reports of disciplinary action. Every
health maintenance
15organization, limited service health organization
and
, preferred provider plan
and
16managed care plan shall notify the medical examining board or appropriate
17affiliated credentialing board attached to the medical examining board of any
18disciplinary action taken against a
selected participating provider who holds a
19license or certificate granted by the board or affiliated credentialing board.
AB768-ASA1,430,23
21609.20 (title)
Rules for preferred provider
and managed care plans. 22(intro.) The commissioner shall promulgate rules
applicable relating to preferred
23provider plans
and managed care plans for all of the following purposes:
AB768-ASA1,431,2
1609.20
(1) To ensure that
enrolled participants enrollees are not forced to travel
2excessive distances to receive health care services.
AB768-ASA1,431,54
609.20
(2) To ensure that the continuity of patient care for
enrolled participants 5is not disrupted enrollees meets the requirements under s. 609.24.
AB768-ASA1,431,147
609.20
(4) To ensure that employes offered a
health maintenance organization
8or a preferred provider plan that provides comprehensive services under s. 609.10
9(1) (a) are given adequate notice of the opportunity to enroll
and, as well as complete
10and understandable information under s. 609.10 (1) (c) concerning the differences
11between the
health maintenance organization or preferred provider plan and the
12standard plan, including differences between providers available and differences
13resulting from special limitations or requirements imposed by an institutional
14provider because of its affiliation with a religious organization.
AB768-ASA1,431,18
16609.22 Access standards. (1) Providers. A managed care plan shall include
17a sufficient number, and sufficient types, of providers to meet the anticipated needs
18of its enrollees, with respect to covered benefits.
AB768-ASA1,431,21
19(2) Adequate choice. A managed care plan shall ensure that, with respect to
20covered benefits, each enrollee has adequate choice among participating providers
21and that the providers are accessible and qualified.
AB768-ASA1,432,3
22(3) Primary provider selection. A managed care plan shall permit each
23enrollee to select his or her own primary provider from a list of participating primary
24care physicians and any other participating providers that are authorized by the
25managed care plan to serve as primary providers. The list shall be updated on an
1ongoing basis and shall include a sufficient number of primary care physicians and
2any other participating providers authorized by the plan to serve as primary
3providers who are accepting new enrollees.
AB768-ASA1,432,10
4(4) Specialist providers. (a) A managed care plan shall allow all enrollees
5under the plan to have access to specialist physicians on a timely basis when
6specialty medical care is warranted, with respect to covered benefits. An enrollee
7shall be allowed to choose among participating specialist physicians, within the
8limitations of the managed care plan, when a referral is made for specialty care, with
9respect to covered benefits. A managed care plan shall clearly disclose to enrollees
10any limitations.