AB927: Bill Text

AB927,6,25 609.01 (1p) "Health care professional" means any individual licensed, registered, permitted or certified by the department of health and family services or the department of regulation and licensing to provide health care services, items or supplies in this state.

AB927, s. 11 Section 11. 609.01 (2) of the statutes is amended to read:

AB927,7,7 609.01 (2) "Health maintenance organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization participating in the plan.

AB927, s. 12 Section 12. 609.01 (3) of the statutes is amended to read:

AB927,7,14 609.01 (3) "Limited service health organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization participating in the plan.

AB927, s. 13 Section 13. 609.01 (3c) of the statutes is created to read:

AB927,7,21 609.01 (3c) "Managed care plan" means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with or employed by the insurer offering the health benefit plan. The term includes a health maintenance organization and a preferred provider plan, but does not include a limited service health organization.

AB927, s. 14 Section 14. 609.01 (3m) of the statutes is created to read:

AB927,8,2 609.01 (3m) "Participating" means, with respect to a physician or other provider, under contract with a managed care plan or limited service health organization to provide health care services, items or supplies to enrollees of the plan.

AB927, s. 15 Section 15. 609.01 (3r) of the statutes is created to read:

AB927,8,4 609.01 (3r) "Physician" has the meaning given in s. 448.01 (5).

AB927, s. 16 Section 16. 609.01 (4) of the statutes is amended to read:

AB927,8,11 609.01 (4) "Preferred provider plan" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers selected by the organization participating in the plan.

AB927, s. 17 Section 17. 609.01 (4m) of the statutes is created to read:

AB927,8,14 609.01 (4m) "Primary care physician" means a physician specializing in family medical practice, general internal medicine, obstetrics and gynecology or pediatrics.

AB927, s. 18 Section 18. 609.01 (5) of the statutes is repealed and recreated to read:

AB927,8,17 609.01 (5) "Primary provider" means a participating health care professional who coordinates, supervises and may provide ongoing care to an enrollee.

AB927, s. 19 Section 19. 609.01 (6) of the statutes is repealed and recreated to read:

AB927,8,20 609.01 (6) "Specialist physician" means a physician who is not a primary care physician.

AB927, s. 20 Section 20. 609.01 (7) of the statutes is amended to read:

AB927,8,23 609.01 (7) "Standard plan" means a health care plan other than a health maintenance organization or a preferred provider that is not a managed care plan.

AB927, s. 21 Section 21. 609.05 (1) of the statutes is amended to read:

AB927,9,4 609.05 (1) Except as provided in subs. (2) and (3), a health maintenance organization, limited service health organization or preferred provider managed care plan shall permit its enrolled participants enrollees to choose freely among selected participating providers.

AB927, s. 22 Section 22. 609.05 (2) of the statutes is amended to read:

AB927,9,8 609.05 (2) A Subject to s. 609.22 (4), a health care plan under sub. (1) may require an enrolled participant enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

AB927, s. 23 Section 23. 609.05 (3) of the statutes is amended to read:

AB927,9,14 609.05 (3) Except as provided in ss. 609.65 and 609.655, a health care plan under sub. (1) may require an enrolled participant enrollee to obtain a referral from the primary provider designated under sub. (2) to another selected participating provider prior to obtaining health care services from the other selected that participating provider.

AB927, s. 24 Section 24. 609.10 (1) (a) of the statutes is amended to read:

AB927,9,21 609.10 (1) (a) Except as provided in subs. (2) to (4), an employer that offers any of its employes a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employes a standard plan, as provided in pars. (b) and (c), that provides at least substantially equivalent coverage of health care expenses and that is not a health maintenance organization or a preferred provider plan.

AB927, s. 25 Section 25. 609.15 (1) (intro.) of the statutes is amended to read:

AB927,9,25 609.15 (1) (intro.)  Each health maintenance organization, limited service health organization and preferred provider managed care plan shall do all of the following:

AB927, s. 26 Section 26. 609.15 (1) (a) of the statutes is amended to read:

AB927,10,4 609.15 (1) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) for the resolution of enrolled participants' enrollees' grievances with the health care plan.

AB927, s. 27 Section 27. 609.15 (1) (b) of the statutes is amended to read:

AB927,10,8 609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).

AB927, s. 28 Section 28. 609.15 (2) (a) of the statutes is amended to read:

AB927,10,11 609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.

AB927, s. 29 Section 29. 609.15 (2) (b) of the statutes is amended to read:

AB927,10,17 609.15 (2) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrolled participant enrollee other than the grievant, if an enrolled participant enrollee is available to serve on the grievance panel.

AB927, s. 30 Section 30. 609.17 of the statutes is amended to read:

AB927,10,24 609.17 Reports of disciplinary action. Every health maintenance organization, limited service health organization and preferred provider managed care plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a selected participating provider who holds a license or certificate granted by the board or affiliated credentialing board.

AB927, s. 31 Section 31. 609.20 (intro.) of the statutes is amended to read:

AB927,11,3 609.20 Rules for preferred provider managed care plans. (intro.) The commissioner shall promulgate rules applicable to preferred provider plans relating to managed care plans for all of the following purposes:

AB927, s. 32 Section 32. 609.20 (1) of the statutes is amended to read:

AB927,11,6 609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.

AB927, s. 33 Section 33. 609.20 (2) of the statutes is amended to read:

AB927,11,9 609.20 (2) To ensure that the continuity of patient care for enrolled participants enrollees is not disrupted.

AB927, s. 34 Section 34. 609.20 (4) of the statutes is amended to read:

AB927,11,18 609.20 (4) To ensure that employes offered a health maintenance organization or a preferred provider plan that provides comprehensive services under s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and, as well as complete and understandable information under s. 609.10 (1) (c) concerning the differences between the health maintenance organization or preferred provider plan and the standard plan, including differences between providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization.

AB927, s. 35 Section 35. 609.22 of the statutes is created to read:

AB927,11,22 609.22 Access standards. (1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.

AB927,11,25 (2) 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.

AB927,12,5 (3) Specialist providers. (a) 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, with respect to covered benefits. An enrollee shall be allowed to choose among participating specialist physicians when a referral is made for specialty care, with respect to covered benefits.

AB927,12,10 (b) If the treatment of a specific condition for which coverage is provided under the plan 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.

AB927,12,15 (4) Primary provider selection. (a) Subject to par. (b), 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 a sufficient number of health care professionals who are accepting new enrollees.

AB927,12,18 (b) A managed care plan shall establish a system under which an enrollee with a chronic disease or other special needs for which coverage is provided under the plan may select a participating specialist physician as his or her primary provider.

AB927,12,20 (5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

AB927,12,23 (6) Emergency care. If a managed care plan provides coverage of emergency services, with respect to covered benefits, the managed care plan shall do all of the following:

AB927,13,3 (a) Cover, and reimburse expenses for, emergency care for which coverage is provided under the plan and that is obtained without prior authorization for the treatment of an emergency medical condition.

AB927,13,8 (b) Cover, and reimburse expenses for, emergency or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan, regardless of where the care is provided.

AB927,13,14 (7) 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 for which coverage is provided under the plan. 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, for which coverage is provided under the plan.

AB927,13,20 (8) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. 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.

AB927, s. 36 Section 36. 609.24 of the statutes is created to read:

AB927,14,3 609.24 Continuity of care. (1) Requirement to provide access. (a) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:

AB927,14,5 1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.

AB927,14,8 2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee's enrollment or most recent coverage renewal, whichever is later.

AB927,14,10 (b) Except as provided in pars. (c) and (d), a managed care plan shall provide the coverage required under par. (a) for the following period of time:

AB927,14,12 1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.

AB927,14,15 2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.

AB927,14,21 (c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is a specialist physician and whose participation with the plan terminates, the managed care plan is required to provide the coverage under par. (a) only for the remainder of the course of treatment, or for 90 days after the provider's participation with the plan terminates, whichever is shorter.

AB927,14,23 (d) The coverage required under par. (a) need not be provided or may be discontinued if any of the following applies:

AB927,14,25 1. The provider is a health care professional who no longer practices in the managed care plan's geographic service area.

AB927,15,2 2. The insurer issuing the managed care plan terminates or terminated the provider's contract for misconduct on the part of the provider.

AB927,15,5 (e) An insurer issuing a managed care plan shall include in its provider contracts provisions that are reasonable or necessary for compliance with this section.

AB927,15,8 (2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.

AB927, s. 37 Section 37. 609.26 of the statutes is created to read:

AB927,15,12 609.26 Drugs and devices. (1) (a) In this subsection, "off-label use" means a use that is not approved by the federal food and drug administration for a drug or device that is approved by the federal food and drug administration.

AB927,15,15 (b) A managed care plan that provides coverage of prescription drugs or devices may not deny coverage of a prescribed drug or device solely on the basis that the drug or device is prescribed for an off-label use.

AB927,15,18 (2) A managed care plan that provides coverage of only certain specified prescription drugs or devices shall provide coverage of any other prescription drug or device whenever the drug or device is medically necessary.

AB927, s. 38 Section 38. 609.28 of the statutes is created to read:

AB927,15,23 609.28 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:

AB927,15,24 (a) Who is authorized to make a determination on the limitation.

AB927,16,2 (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.

AB927,16,9 (2) Denial of treatment. A managed care plan that receives a request for prior authorization of an experimental procedure that includes sufficient information upon which to make a decision shall, within 5 days after receiving the request, issue a coverage decision. If the 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, as part of its coverage decision, provide the enrollee with a denial letter that includes all of the following:

AB927,16,10 (a) The name and title of the individual making the decision.

AB927,16,12 (b) A statement setting forth the specific medical and scientific reasons for denying coverage.

AB927,16,14 (c) Notice of the enrollee's right to appeal and a description of the appeal procedure.

AB927, s. 39 Section 39. 609.30 of the statutes is created to read:

AB927,16,19 609.30 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.