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, s. 566ccn 18Section 566ccn. 609.01 (2) of the statutes is amended to read:
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, s. 566ccp 25Section 566ccp. 609.01 (3) of the statutes is amended to read:
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, s. 566ccr 7Section 566ccr. 609.01 (3c) of the statutes is created to read:
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, s. 566cct 13Section 566cct. 609.01 (3m) of the statutes is created to read:
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, s. 566ccv 19Section 566ccv. 609.01 (3r) of the statutes is created to read:
AB768-ASA1,427,2020 609.01 (3r) "Physician" has the meaning given in s. 448.01 (5).
AB768-ASA1, s. 566ccx 21Section 566ccx. 609.01 (4) of the statutes is amended to read:
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, s. 566ccz 3Section 566ccz. 609.01 (4m) of the statutes is created to read:
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, s. 566cdd 6Section 566cdd. 609.01 (5) of the statutes is repealed and recreated to read:
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, s. 566cdf 11Section 566cdf. 609.01 (6) of the statutes is repealed and recreated to read:
AB768-ASA1,428,1312 609.01 (6) "Specialist physician" means a physician who is not a primary care
13physician.
AB768-ASA1, s. 566cdg 14Section 566cdg. 609.05 (1) of the statutes is amended to read:
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, s. 566cdi 19Section 566cdi. 609.05 (2) of the statutes is amended to read:
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, s. 566cdk 24Section 566cdk. 609.05 (3) of the statutes is amended to read:
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, s. 566cdm 7Section 566cdm. 609.10 (1) (a) of the statutes is amended to read:
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, s. 566cdo 14Section 566cdo. 609.15 (1) (intro.) of the statutes is amended to read:
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, s. 566cdq 18Section 566cdq. 609.15 (1) (a) of the statutes is amended to read:
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, s. 566cds 23Section 566cds. 609.15 (1) (b) of the statutes is amended to read:
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, s. 566cdu 4Section 566cdu. 609.15 (2) (a) of the statutes is amended to read:
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, s. 566cdw 7Section 566cdw. 609.15 (2) (b) of the statutes is amended to read:
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, s. 566cdy 13Section 566cdy. 609.17 of the statutes is amended to read:
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, s. 566cfc 20Section 566cfc. 609.20 (intro.) of the statutes is amended to read:
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, s. 566cfe 24Section 566cfe. 609.20 (1) of the statutes is amended to read:
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, s. 566cfg 3Section 566cfg. 609.20 (2) of the statutes is amended to read:
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, s. 566cfi 6Section 566cfi. 609.20 (4) of the statutes is amended to read:
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, s. 566cfk 15Section 566cfk. 609.22 of the statutes is created to read:
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.
AB768-ASA1,432,1511 (b) If the treatment of a specific condition for which coverage is provided under
12the plan requires the services of a particular type of specialist physician and a
13managed care plan has no participating specialist physicians of that type, the
14managed care plan shall provide enrollees with the specific condition with coverage
15for the services of nonparticipating specialist physicians of that type.
AB768-ASA1,432,2016 (c) 1. If a managed care plan requires a referral to a specialist physician for
17coverage of the specialist physician's services, the managed care plan shall establish
18a procedure by which an enrollee may apply for a standing referral to a specialist
19physician. The procedure must specify the criteria and conditions that must be met
20in order for an enrollee to obtain a standing referral.
AB768-ASA1,433,421 2. A managed care plan may require the enrollee's primary provider to remain
22responsible for coordinating the care of an enrollee who receives a standing referral
23to a specialist physician. A managed care plan may restrict the specialist physician
24from making any secondary referrals without prior approval by the enrollee's
25primary provider. If an enrollee requests primary care services from a specialist

1physician to whom the enrollee has a standing referral, the specialist physician, in
2agreement with the enrollee and the enrollee's primary provider, may provide
3primary care services to the enrollee in accordance with procedures established by
4the managed care plan.
AB768-ASA1,433,75 3. A managed care plan must include information regarding referral
6procedures in policies or certificates provided to enrollees and must provide such
7information to an enrollee or prospective enrollee upon request.
AB768-ASA1,433,9 8(5) Second opinions. A managed care plan shall provide an enrollee with
9coverage for a 2nd opinion from another participating provider.
AB768-ASA1,433,12 10(6) Emergency care. Notwithstanding s. 632.85, if a managed care plan
11provides coverage of emergency services, with respect to covered benefits, the
12managed care plan shall do all of the following:
AB768-ASA1,433,1513 (a) Cover emergency medical services for which coverage is provided under the
14plan and that are obtained without prior authorization for the treatment of an
15emergency medical condition.
AB768-ASA1,433,1916 (b) Cover emergency medical services or urgent care for which coverage is
17provided under the plan and that is provided to an individual who has coverage
18under the plan as a dependent child and who is a full-time student attending school
19outside of the geographic service area of the plan.
AB768-ASA1,433,25 20(7) Telephone access. A managed care plan shall provide telephone access for
21sufficient time during business and evening hours to ensure that enrollees have
22adequate access to routine health care services for which coverage is provided under
23the plan. A managed care plan shall provide 24-hour telephone access to the plan
24or to a participating provider for emergency care, or authorization for care, for which
25coverage is provided under the plan.
AB768-ASA1,434,6
1(8) Access plan for certain enrollees. A managed care plan shall develop an
2access plan to meet the needs, with respect to covered benefits, of its enrollees who
3are members of underserved populations. If a significant number of enrollees of the
4plan customarily use languages other than English, the managed care plan shall
5provide access to translation services fluent in those languages to the greatest extent
6possible.
AB768-ASA1, s. 566cfm 7Section 566cfm. 609.24 of the statutes is created to read:
AB768-ASA1,434,14 8609.24 Continuity of care. (1) Requirement to provide access. (a) Subject
9to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall, with
10respect to covered benefits, provide coverage to an enrollee for the services of a
11provider, regardless of whether the provider is a participating provider at the time
12the services are provided, if the managed care plan represented that the provider
13was, or would be, a participating provider in marketing materials that were provided
14or available to the enrollee at any of the following times:
AB768-ASA1,434,1615 1. If the plan under which the enrollee has coverage has an open enrollment
16period, the most recent open enrollment period.
AB768-ASA1,434,1917 2. If the plan under which the enrollee has coverage has no open enrollment
18period, the time of the enrollee's enrollment or most recent coverage renewal,
19whichever is later.
AB768-ASA1,434,2220 (b) Except as provided in par. (d), a managed care plan shall provide the
21coverage required under par. (a) with respect to the services of a provider who is a
22primary care physician for the following period of time:
AB768-ASA1,434,2423 1. For an enrollee of a plan with no open enrollment period, until the end of the
24current plan year.
AB768-ASA1,435,3
12. For an enrollee of a plan with an open enrollment period, until the end of the
2plan year for which it was represented that the provider was, or would be, a
3participating provider.
AB768-ASA1,435,84 (c) Except as provided in par. (d), if an enrollee is undergoing a course of
5treatment with a participating provider who is not a primary care physician and
6whose participation with the plan terminates, the managed care plan shall provide
7the coverage under par. (a) with respect to the services of the provider for the
8following period of time:
AB768-ASA1,435,129 1. Except as provided in subd. 2., for the remainder of the course of treatment
10or for 90 days after the provider's participation with the plan terminates, whichever
11is shorter, except that the coverage is not required to extend beyond the period
12specified in par. (b) 1. or 2., whichever applies.
AB768-ASA1,435,1513 2. If maternity care is the course of treatment and the enrollee is a woman who
14is in the 2nd or 3rd trimester of pregnancy when the provider's participation with the
15plan terminates, until the completion of postpartum care for the woman and infant.
AB768-ASA1,435,1716 (d) The coverage required under this section need not be provided or may be
17discontinued if any of the following applies:
AB768-ASA1,435,1918 1. The provider no longer practices in the managed care plan's geographic
19service area.
AB768-ASA1,435,2120 2. The insurer issuing the managed care plan terminates or terminated the
21provider's contract for misconduct on the part of the provider.
AB768-ASA1,435,2422 (e) 1. An insurer issuing a managed care plan shall include in its provider
23contracts provisions addressing reimbursement to providers for services rendered
24under this section.
AB768-ASA1,436,3
12. If a contract between a managed care plan and a provider does not address
2reimbursement for services rendered under this section, the insurer shall reimburse
3the provider according to the most recent contracted rate.
AB768-ASA1,436,6 4(2) Medical necessity provisions. This section does not preclude the
5application of any provisions related to medical necessity that are generally
6applicable under the plan.
AB768-ASA1,436,11 7(3) Hold harmless requirements. A provider that receives or is due
8reimbursement for services provided to an enrollee under this section is subject to
9s. 609.91 with respect to the enrollee, regardless of whether the provider is a
10participating provider in the enrollee's plan and regardless of whether the enrollee's
11plan is a health maintenance organization.
AB768-ASA1, s. 566cfo 12Section 566cfo. 609.30 of the statutes is created to read:
AB768-ASA1,436,16 13609.30 Provider disclosures. (1) Plan may not contract. A managed care
14plan may not contract with a participating provider to limit the provider's disclosure
15of information, to or on behalf of an enrollee, about the enrollee's medical condition
16or treatment options.
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