AB673: Bill Text

AB673,10,5 (e) The availability of nonparticipating specialist physicians for enrollees whose medical conditions require services that cannot be provided by participating specialist physicians.

AB673,10,10 (2) Nonparticipating specialists. If the treatment of a specific condition requires the services of a particular type of specialist physician and a managed care plan has no participating specialist physicians of that type, the managed care plan shall provide enrollees with the specific condition with coverage for the services of nonparticipating specialist physicians of that type.

AB673,10,15 (3) Telephone access. A managed care plan shall provide telephone access to the plan for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services. A managed care plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care or authorization for care.

AB673,10,20 (4) Standards for appointment scheduling. A managed care plan shall establish standards for reasonable waiting times for obtaining appointments for health care services, except for emergency care. The standards shall include scheduling guidelines based on the type of health care service for which an appointment is being made.

AB673,10,23 (5) Emergency care. A managed care plan shall cover, and reimburse expenses for, emergency care obtained without prior authorization for the treatment of an emergency medical condition.

AB673,11,4 (6) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs of its enrollees who are members of underserved populations. The managed care plan shall provide culturally appropriate services to the greatest extent possible. If a significant number of enrollees of the plan customarily use languages other than English, the managed care plan shall provide access to personnel who are fluent in those languages to the greatest extent possible.

AB673,11,12 (7) Enrollees held harmless for claims. A limited service health organization or a preferred provider plan shall hold an enrollee harmless against any claim from a participating provider for payment of any portion of the cost of covered health care services. This subsection does not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the limited service health organization insurer or the preferred provider plan insurer. A health maintenance organization is subject to ss. 609.91 to 609.94.

AB673, s. 34 Section 34. 609.24 of the statutes is created to read:

AB673,11,16 609.24 Choice of providers. (1) Adequate choice. A managed care plan shall ensure that each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.

AB673,11,20 (2) Primary providers. Except as provided in sub. (3), a managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating health care professionals. The list shall be updated on an ongoing basis and shall include all of the following:

AB673,11,22 (a) A sufficient number of health care professionals who are accepting new enrollees.

AB673,11,25 (b) A sufficient diversity of health care professionals to adequately meet the needs of an enrollee population with varied characteristics, including age, gender, race and health status.

AB673,12,3 (3) Specialist providers. (a) A managed care plan shall establish a system under which an enrollee with a chronic disease or other special needs may select a participating specialist physician as his or her primary provider.

AB673,12,7 (b) A managed care plan shall allow all enrollees under the plan to have access to specialist physicians on a timely basis when specialty medical care is warranted. An enrollee shall be allowed to choose among participating specialist physicians when a referral is made for specialty care.

AB673,12,12 (4) Point-of-service option. A managed care plan shall offer a point-of-service option, under which an enrollee may obtain covered services from a nonparticipating provider of the enrollee's choice. Under the point-of-service option, the enrollee may be required to pay a reasonable portion of the cost of those services.

AB673,12,14 (5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

AB673, s. 35 Section 35. 609.26 of the statutes is created to read:

AB673,12,22 609.26 Drugs and devices. (1) Coverage. (a) A managed care plan shall provide coverage of any drug or device that is approved for use by the federal food and drug administration and that is determined by a treating participating provider to be medically appropriate and necessary for treatment of an enrollee's condition, regardless of whether the drug or device is prescribed by the treating participating provider for the use for which the drug or device is approved by the federal food and drug administration.

AB673,12,24 (b) A treating participating provider shall determine the drug therapy that is appropriate for his or her patient.

AB673,13,2 (c) Prospective review of drug therapy may deny coverage only if any of the following apply:

AB673,13,3 1. A coverage limitation has been reached with respect to the enrollee.

AB673,13,4 2. The enrollee has committed fraud with respect to obtaining the drug.

AB673,13,8 (2) Drug utilization review program. (a) A managed care plan shall establish and operate a drug utilization review program. The primary goal of the program shall be to enhance quality of care for enrollees by ensuring appropriate drug therapy.

AB673,13,9 (b) The program under par. (a) shall include all of the following:

AB673,13,10 1. Retrospective review of prescription drugs furnished to enrollees.

AB673,13,12 2. Ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees.

AB673,13,14 3. An educational outreach program for physicians, pharmacists and enrollees regarding the appropriate use of prescription drugs.

AB673,13,15 (c) The program under par. (a) shall utilize all of the following:

AB673,13,16 1. Clinically relevant criteria and standards for drug therapy.

AB673,13,18 2. Nonproprietary criteria and standards developed and revised through an open, professional consensus process.

AB673,13,19 3. Interventions that focus on improving therapeutic outcomes.

AB673, s. 36 Section 36. 609.28 of the statutes is created to read:

AB673,13,24 609.28 Experimental treatment. (1) Disclosure of limitations. A managed care plan that limits coverage for experimental treatment shall define the limitation and disclose the limits in any agreement or certificate of coverage. This disclosure shall include the following information:

AB673,13,25 (a) Who is authorized to make a determination on the limitation.

AB673,14,2 (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.

AB673,14,7 (2) Denial of treatment. If a managed care plan denies coverage of an experimental treatment, procedure, drug or device for an enrollee who has a terminal condition or illness, the managed care plan shall provide the enrollee with a denial letter within 20 working days after the request for coverage is submitted. The denial letter shall include all of the following:

AB673,14,8 (a) The name and title of the individual making the decision.

AB673,14,10 (b) A statement setting forth the specific medical and scientific reasons for denying coverage.

AB673,14,12 (c) A description of any alternative treatment, procedures, drugs or devices covered by the plan.

AB673,14,13 (d) A written copy of the plan's grievance and appeal procedure.

AB673, s. 37 Section 37. 609.30 of the statutes is created to read:

AB673,14,18 609.30 Provider disclosures. (1) Plan may not contract. A managed care plan may not contract with a participating provider to limit the provider's disclosure of information, to or on behalf of an enrollee, about the enrollee's medical condition or treatment options.

AB673,14,22 (2) Plan may not penalize or terminate. (a) A managed care plan may not penalize a participating provider for discussing with an enrollee financial incentives offered by the plan or other financial arrangements between the plan and the provider.

AB673,15,3 (b) A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A managed care plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.

AB673, s. 38 Section 38. 609.32 of the statutes is created to read:

AB673,15,8 609.32 Quality assurance. (1) Standards. A managed care plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:

AB673,15,9 (a) An ongoing, written internal quality assurance program.

AB673,15,10 (b) Specific written guidelines for quality of care studies and monitoring.

AB673,15,11 (c) Performance and clinical outcomes-based criteria.

AB673,15,13 (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

AB673,15,14 (e) A plan for gathering and assessing data.

AB673,15,15 (f) A peer review process.

AB673,15,23 (2) Selection and evaluation of providers. (a) A managed care plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider's license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.

AB673,16,2 (b) A managed care plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider's initial acceptance for participation. The reevaluation shall include all of the following:

AB673,16,3 1. Updating the previous review criteria.

AB673,16,5 2. Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

AB673,16,7 (c) A managed care plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.

AB673, s. 39 Section 39. 609.34 of the statutes is created to read:

AB673,16,12 609.34 Clinical decision-making. (1) Medical director. A managed care plan shall appoint a physician as medical director. The medical director shall be responsible for treatment policies, protocols, quality assurance activities and utilization management decisions of the plan.

AB673,16,15 (2) Incentives. A managed care plan shall inform enrollees of any financial arrangement between the plan and a participating physician or pharmacist that includes or operates as an incentive or a bonus for restricting services.

AB673, s. 40 Section 40. 609.36 of the statutes is created to read:

AB673,16,19 609.36 Data systems and confidentiality. (1) Information and data reporting. (a) A managed care plan shall provide to the commissioner information related to all of the following:

AB673,16,20 1. The structure of the plan.

AB673,16,21 2. The plan's decision-making process.

AB673,16,22 3. Health care benefits and exclusions.

AB673,16,23 4. Cost-sharing requirements.

AB673,16,24 5. Participating providers.

AB673,17,2 (b) A managed care plan shall collect and annually report to the commissioner the following data:

AB673,17,3 1. Gross outpatient and hospitalization data.

AB673,17,4 2. Enrollee clinical outcomes data.

AB673,17,6 (c) Subject to sub. (2), the information and data reported under pars. (a) and (b) shall be open to public inspection under ss. 19.31 to 19.39.

AB673,17,9 (2) Confidentiality. A managed care plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.

AB673, s. 41 Section 41. 609.38 of the statutes is created to read:

AB673,17,15 609.38 Oversight. On an annual basis, the office shall perform audits of managed care plans in the state to review enrollee outcome data, enrollee service data and operational and other financial data. The commissioner shall by rule develop standards for managed care plans for compliance with the requirements under this chapter.

AB673, s. 42 Section 42. 609.65 (1) (intro.) of the statutes is amended to read:

AB673,17,25 609.65 (1) (intro.)  If an enrolled participant of a health maintenance organization, limited service health organization or preferred provider enrollee of a managed care plan is examined, evaluated or treated for a nervous or mental disorder pursuant to an emergency detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the limitations regarding selected participating providers, primary providers and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the health maintenance organization, limited service health organization or preferred provider managed care plan shall do all of the following:

AB673, s. 43 Section 43. 609.65 (1) (a) of the statutes is amended to read:

AB673,18,7 609.65 (1) (a) If the provider performing the examination, evaluation or treatment has a provider agreement with the health maintenance organization, limited service health organization or preferred provider managed care plan which covers the provision of that service to the enrolled participant enrollee, make the service available to the enrolled participant enrollee in accordance with the terms of the health care plan and the provider agreement.

AB673, s. 44 Section 44. 609.65 (1) (b) (intro.) of the statutes is amended to read:

AB673,18,16 609.65 (1) (b) (intro.) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the health maintenance organization, limited service health organization or preferred provider managed care plan which covers the provision of that service to the enrolled participant enrollee, reimburse the provider for the examination, evaluation or treatment of the enrolled participant enrollee in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:

AB673, s. 45 Section 45. 609.65 (1) (b) 1. of the statutes is amended to read:

AB673,18,22 609.65 (1) (b) 1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the health maintenance organization, limited service health organization or preferred provider managed care plan could have provided the service through a provider with whom it has a provider agreement.

AB673, s. 46 Section 46. 609.65 (1) (b) 2. of the statutes is amended to read:

AB673,19,3 609.65 (1) (b) 2. The service is provided pursuant to an emergency detention under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20 and the provider notifies the health maintenance organization, limited service health organization or preferred provider managed care plan within 72 hours after the initial provision of the service.

AB673, s. 47 Section 47. 609.65 (2) of the statutes is amended to read:

AB673,19,11 609.65 (2) If after receiving notice under sub. (1) (b) 2. the health maintenance organization, limited service health organization or preferred provider managed care plan arranges for services to be provided by a provider with whom it has a provider agreement, the health maintenance organization, limited service health organization or preferred provider managed care plan is not required to reimburse a provider under sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.

AB673, s. 48 Section 48. 609.65 (3) of the statutes is amended to read:

AB673,19,22 609.65 (3) A health maintenance organization, limited service health organization or preferred provider managed care plan is only required to make available, or make reimbursement for, an examination, evaluation or treatment under sub. (1) to the extent that the health maintenance organization, limited service health organization or preferred provider managed care plan would have made the medically necessary service available to the enrolled participant enrollee or reimbursed the provider for the service if any referrals required under s. 609.05 (3) had been made and the service had been performed by a participating provider selected by the health maintenance organization, limited service health organization or preferred provider plan.

AB673, s. 49 Section 49. 609.655 (2) of the statutes is amended to read: