AB673, s. 28 14Section 28. 609.17 of the statutes is amended to read:
AB673,8,20 15609.17 Reports of disciplinary action. Every health maintenance
16organization, limited service health organization and preferred provider
managed
17care
plan shall notify the medical examining board or appropriate affiliated
18credentialing board attached to the medical examining board of any disciplinary
19action taken against a selected participating provider who holds a license or
20certificate granted by the board or affiliated credentialing board.
AB673, s. 29 21Section 29. 609.20 (intro.) of the statutes is amended to read:
AB673,8,24 22609.20 Rules for preferred provider managed care plans. (intro.) The
23commissioner shall promulgate rules applicable to preferred provider plans relating
24to managed care plans
for all of the following purposes:
AB673, s. 30 25Section 30. 609.20 (1) of the statutes is amended to read:
AB673,9,2
1609.20 (1) To ensure that enrolled participants enrollees are not forced to travel
2excessive distances to receive health care services.
AB673, s. 31 3Section 31. 609.20 (2) of the statutes is amended to read:
AB673,9,54 609.20 (2) To ensure that the continuity of patient care for enrolled participants
5enrollees is not disrupted.
AB673, s. 32 6Section 32. 609.20 (4) of the statutes is amended to read:
AB673,9,147 609.20 (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 complete and
10understandable 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.
AB673, s. 33 15Section 33. 609.22 of the statutes is created to read:
AB673,9,20 16609.22 Access to personnel and facilities. (1) Providers. A managed care
17plan shall include a sufficient number, and sufficient types, of primary care and
18specialist physicians throughout the service area of the plan to meet the anticipated
19needs of its enrollees and to provide its enrollees with a meaningful choice among
20physicians. A managed care plan shall offer all of the following:
AB673,9,2121 (a) Adequate accessible acute care hospital services for all of its enrollees.
AB673,9,2322 (b) An adequate number of accessible primary care physicians for all of its
23enrollees.
AB673,9,2524 (c) Subject to sub. (2), an adequate number of accessible specialist physicians
25for all of its enrollees within a reasonable distance or travel time.
AB673,10,2
1(d) The availability of specialty medical services, including physical therapy,
2occupational therapy and rehabilitation services.
AB673,10,53 (e) The availability of nonparticipating specialist physicians for enrollees
4whose medical conditions require services that cannot be provided by participating
5specialist physicians.
AB673,10,10 6(2) Nonparticipating specialists. If the treatment of a specific condition
7requires the services of a particular type of specialist physician and a managed care
8plan has no participating specialist physicians of that type, the managed care plan
9shall provide enrollees with the specific condition with coverage for the services of
10nonparticipating specialist physicians of that type.
AB673,10,15 11(3) Telephone access. A managed care plan shall provide telephone access to
12the plan for sufficient time during business and evening hours to ensure that
13enrollees have adequate access to routine health care services. A managed care plan
14shall provide 24-hour telephone access to the plan or to a participating provider for
15emergency care or authorization for care.
AB673,10,20 16(4) Standards for appointment scheduling. A managed care plan shall
17establish standards for reasonable waiting times for obtaining appointments for
18health care services, except for emergency care. The standards shall include
19scheduling guidelines based on the type of health care service for which an
20appointment is being made.
AB673,10,23 21(5) Emergency care. A managed care plan shall cover, and reimburse expenses
22for, emergency care obtained without prior authorization for the treatment of an
23emergency medical condition.
AB673,11,4 24(6) Access plan for certain enrollees. A managed care plan shall develop an
25access plan to meet the needs of its enrollees who are members of underserved

1populations. The managed care plan shall provide culturally appropriate services
2to the greatest extent possible. If a significant number of enrollees of the plan
3customarily use languages other than English, the managed care plan shall provide
4access to personnel who are fluent in those languages to the greatest extent possible.
AB673,11,12 5(7) Enrollees held harmless for claims. A limited service health organization
6or a preferred provider plan shall hold an enrollee harmless against any claim from
7a participating provider for payment of any portion of the cost of covered health care
8services. This subsection does not affect the liability of an enrollee, policyholder or
9insured for any deductibles, copayments or premiums owed under the policy or
10certificate issued by the limited service health organization insurer or the preferred
11provider plan insurer. A health maintenance organization is subject to ss. 609.91 to
12609.94.
AB673, s. 34 13Section 34. 609.24 of the statutes is created to read:
AB673,11,16 14609.24 Choice of providers. (1) Adequate choice. A managed care plan
15shall ensure that each enrollee has adequate choice among participating providers
16and that the providers are accessible and qualified.
AB673,11,20 17(2) Primary providers. Except as provided in sub. (3), a managed care plan
18shall permit each enrollee to select his or her own primary provider from a list of
19participating health care professionals. The list shall be updated on an ongoing basis
20and shall include all of the following:
AB673,11,2221 (a) A sufficient number of health care professionals who are accepting new
22enrollees.
AB673,11,2523 (b) A sufficient diversity of health care professionals to adequately meet the
24needs of an enrollee population with varied characteristics, including age, gender,
25race and health status.
AB673,12,3
1(3) Specialist providers. (a) A managed care plan shall establish a system
2under which an enrollee with a chronic disease or other special needs may select a
3participating specialist physician as his or her primary provider.
AB673,12,74 (b) A managed care plan shall allow all enrollees under the plan to have access
5to specialist physicians on a timely basis when specialty medical care is warranted.
6An enrollee shall be allowed to choose among participating specialist physicians
7when a referral is made for specialty care.
AB673,12,12 8(4) Point-of-service option. A managed care plan shall offer a
9point-of-service option, under which an enrollee may obtain covered services from
10a nonparticipating provider of the enrollee's choice. Under the point-of-service
11option, the enrollee may be required to pay a reasonable portion of the cost of those
12services.
AB673,12,14 13(5) Second opinions. A managed care plan shall provide an enrollee with
14coverage for a 2nd opinion from another participating provider.
AB673, s. 35 15Section 35. 609.26 of the statutes is created to read:
AB673,12,22 16609.26 Drugs and devices. (1) Coverage. (a) A managed care plan shall
17provide coverage of any drug or device that is approved for use by the federal food and
18drug administration and that is determined by a treating participating provider to
19be medically appropriate and necessary for treatment of an enrollee's condition,
20regardless of whether the drug or device is prescribed by the treating participating
21provider for the use for which the drug or device is approved by the federal food and
22drug administration.
AB673,12,2423 (b) A treating participating provider shall determine the drug therapy that is
24appropriate for his or her patient.
AB673,13,2
1(c) Prospective review of drug therapy may deny coverage only if any of the
2following apply:
AB673,13,33 1. A coverage limitation has been reached with respect to the enrollee.
AB673,13,44 2. The enrollee has committed fraud with respect to obtaining the drug.
AB673,13,8 5(2) Drug utilization review program. (a) A managed care plan shall establish
6and operate a drug utilization review program. The primary goal of the program
7shall be to enhance quality of care for enrollees by ensuring appropriate drug
8therapy.
AB673,13,99 (b) The program under par. (a) shall include all of the following:
AB673,13,1010 1. Retrospective review of prescription drugs furnished to enrollees.
AB673,13,1211 2. Ongoing periodic examination of data on outpatient prescription drugs to
12ensure quality therapeutic outcomes for enrollees.
AB673,13,1413 3. An educational outreach program for physicians, pharmacists and enrollees
14regarding the appropriate use of prescription drugs.
AB673,13,1515 (c) The program under par. (a) shall utilize all of the following:
AB673,13,1616 1. Clinically relevant criteria and standards for drug therapy.
AB673,13,1817 2. Nonproprietary criteria and standards developed and revised through an
18open, professional consensus process.
AB673,13,1919 3. Interventions that focus on improving therapeutic outcomes.
AB673, s. 36 20Section 36. 609.28 of the statutes is created to read:
AB673,13,24 21609.28 Experimental treatment. (1) Disclosure of limitations. A
22managed care plan that limits coverage for experimental treatment shall define the
23limitation and disclose the limits in any agreement or certificate of coverage. This
24disclosure shall include the following information:
AB673,13,2525 (a) Who is authorized to make a determination on the limitation.
AB673,14,2
1(b) The criteria the plan uses to determine whether a treatment, procedure,
2drug or device is experimental.
AB673,14,7 3(2) Denial of treatment. If a managed care plan denies coverage of an
4experimental treatment, procedure, drug or device for an enrollee who has a
5terminal condition or illness, the managed care plan shall provide the enrollee with
6a denial letter within 20 working days after the request for coverage is submitted.
7The denial letter shall include all of the following:
AB673,14,88 (a) The name and title of the individual making the decision.
AB673,14,109 (b) A statement setting forth the specific medical and scientific reasons for
10denying coverage.
AB673,14,1211 (c) A description of any alternative treatment, procedures, drugs or devices
12covered by the plan.
AB673,14,1313 (d) A written copy of the plan's grievance and appeal procedure.
AB673, s. 37 14Section 37. 609.30 of the statutes is created to read:
AB673,14,18 15609.30 Provider disclosures. (1) Plan may not contract. A managed care
16plan may not contract with a participating provider to limit the provider's disclosure
17of information, to or on behalf of an enrollee, about the enrollee's medical condition
18or treatment options.
AB673,14,22 19(2) Plan may not penalize or terminate. (a) A managed care plan may not
20penalize a participating provider for discussing with an enrollee financial incentives
21offered by the plan or other financial arrangements between the plan and the
22provider.
AB673,15,323 (b) A participating provider may discuss, with or on behalf of an enrollee, all
24treatment options and any other information that the provider determines to be in
25the best interest of the enrollee. A managed care plan may not penalize or terminate

1the contract of a participating provider because the provider makes referrals to other
2participating providers or discusses medically necessary or appropriate care with or
3on behalf of an enrollee.
AB673, s. 38 4Section 38. 609.32 of the statutes is created to read:
AB673,15,8 5609.32 Quality assurance. (1) Standards. A managed care plan shall
6develop comprehensive quality assurance standards that are adequate to identify,
7evaluate and remedy problems related to access to, and continuity and quality of,
8care. The standards shall include at least all of the following:
AB673,15,99 (a) An ongoing, written internal quality assurance program.
AB673,15,1010 (b) Specific written guidelines for quality of care studies and monitoring.
AB673,15,1111 (c) Performance and clinical outcomes-based criteria.
AB673,15,1312 (d) A procedure for remedial action to address quality problems, including
13written procedures for taking appropriate corrective action.
AB673,15,1414 (e) A plan for gathering and assessing data.
AB673,15,1515 (f) A peer review process.
AB673,15,23 16(2) Selection and evaluation of providers. (a) A managed care plan shall
17develop a process for selecting participating providers, including written policies and
18procedures that the plan uses for review and approval of providers. After consulting
19with appropriately qualified providers, the plan shall establish minimum
20professional requirements for its participating providers. The process for selection
21shall include verification of a provider's license or certificate, including the history
22of any suspensions or revocations, and the history of any liability claims made
23against the provider.
AB673,16,224 (b) A managed care plan shall establish in writing a formal, ongoing process
25for reevaluating each participating provider within a specified number of years after

1the provider's initial acceptance for participation. The reevaluation shall include all
2of the following:
AB673,16,33 1. Updating the previous review criteria.
AB673,16,54 2. Assessing the provider's performance on the basis of such criteria as enrollee
5clinical outcomes, number of complaints and malpractice actions.
AB673,16,76 (c) A managed care plan may not require a participating provider to provide
7services that are outside the scope of his or her license or certificate.
AB673, s. 39 8Section 39. 609.34 of the statutes is created to read:
AB673,16,12 9609.34 Clinical decision-making. (1) Medical director. A managed care
10plan shall appoint a physician as medical director. The medical director shall be
11responsible for treatment policies, protocols, quality assurance activities and
12utilization management decisions of the plan.
AB673,16,15 13(2) Incentives. A managed care plan shall inform enrollees of any financial
14arrangement between the plan and a participating physician or pharmacist that
15includes or operates as an incentive or a bonus for restricting services.
AB673, s. 40 16Section 40. 609.36 of the statutes is created to read:
AB673,16,19 17609.36 Data systems and confidentiality. (1) Information and data
18reporting.
(a) A managed care plan shall provide to the commissioner information
19related to all of the following:
AB673,16,2020 1. The structure of the plan.
AB673,16,2121 2. The plan's decision-making process.
AB673,16,2222 3. Health care benefits and exclusions.
AB673,16,2323 4. Cost-sharing requirements.
AB673,16,2424 5. Participating providers.
AB673,17,2
1(b) A managed care plan shall collect and annually report to the commissioner
2the following data:
AB673,17,33 1. Gross outpatient and hospitalization data.
AB673,17,44 2. Enrollee clinical outcomes data.
AB673,17,65 (c) Subject to sub. (2), the information and data reported under pars. (a) and
6(b) shall be open to public inspection under ss. 19.31 to 19.39.
AB673,17,9 7(2) Confidentiality. A managed care plan shall establish written policies and
8procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical
9records and enrollee communications to ensure confidentiality.
AB673, s. 41 10Section 41. 609.38 of the statutes is created to read:
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