AB927,15,8
6(2) Medical necessity provisions. This section does not preclude the
7application of any provisions related to medical necessity that are generally
8applicable under the plan.
AB927, s. 37
9Section
37. 609.26 of the statutes is created to read:
AB927,15,12
10609.26 Drugs and devices. (1) (a) In this subsection, "off-label use" means
11a use that is not approved by the federal food and drug administration for a drug or
12device that is approved by the federal food and drug administration.
AB927,15,1513
(b)
A managed care plan that provides coverage of prescription drugs or devices
14may not deny coverage of a prescribed drug or device solely on the basis that the drug
15or device is prescribed for an off-label use.
AB927,15,18
16(2) A managed care plan that provides coverage of only certain specified
17prescription drugs or devices shall provide coverage of any other prescription drug
18or device whenever the drug or device is medically necessary.
AB927, s. 38
19Section
38. 609.28 of the statutes is created to read:
AB927,15,23
20609.28 Experimental treatment. (1) Disclosure of limitations. A
21managed care plan that limits coverage for experimental treatment shall define the
22limitation and disclose the limits in any agreement or certificate of coverage. This
23disclosure shall include the following information:
AB927,15,2424
(a) Who is authorized to make a determination on the limitation.
AB927,16,2
1(b) The criteria the plan uses to determine whether a treatment, procedure,
2drug or device is experimental.
AB927,16,9
3(2) Denial of treatment. A managed care plan that receives a request for prior
4authorization of an experimental procedure that includes sufficient information
5upon which to make a decision shall, within 5 days after receiving the request, issue
6a coverage decision. If the managed care plan denies coverage of an experimental
7treatment, procedure, drug or device for an enrollee who has a terminal condition or
8illness, the managed care plan shall, as part of its coverage decision, provide the
9enrollee with a denial letter that includes all of the following:
AB927,16,1010
(a) The name and title of the individual making the decision.
AB927,16,1211
(b) A statement setting forth the specific medical and scientific reasons for
12denying coverage.
AB927,16,1413
(c) Notice of the enrollee's right to appeal and a description of the appeal
14procedure.
AB927, s. 39
15Section
39. 609.30 of the statutes is created to read:
AB927,16,19
16609.30 Provider disclosures. (1)
Plan may not contract. A managed care
17plan may not contract with a participating provider to limit the provider's disclosure
18of information, to or on behalf of an enrollee, about the enrollee's medical condition
19or treatment options.
AB927,16,23
20(2) Plan may not penalize or terminate. (a) A managed care plan may not
21penalize a participating provider for discussing with an enrollee financial incentives
22offered by the plan or other financial arrangements between the plan and the
23provider.
AB927,17,424
(b) A participating provider may discuss, with or on behalf of an enrollee, all
25treatment options and any other information that the provider determines to be in
1the best interest of the enrollee. A managed care plan may not penalize or terminate
2the contract of a participating provider because the provider makes referrals to other
3participating providers or discusses medically necessary or appropriate care with or
4on behalf of an enrollee.
AB927, s. 40
5Section
40. 609.32 of the statutes is created to read:
AB927,17,9
6609.32 Quality assurance. (1) Standards. A managed care plan shall
7develop comprehensive quality assurance standards that are adequate to identify,
8evaluate and remedy problems related to access to, and continuity and quality of,
9care. The standards shall include at least all of the following:
AB927,17,1010
(a) An ongoing, written internal quality assurance program.
AB927,17,1111
(b) Specific written guidelines for quality of care studies and monitoring.
AB927,17,1212
(c) Performance and clinical outcomes-based criteria.
AB927,17,1413
(d) A procedure for remedial action to address quality problems, including
14written procedures for taking appropriate corrective action.
AB927,17,1515
(e) A plan for gathering and assessing data.
AB927,17,1616
(f) A peer review process.
AB927,17,24
17(2) Selection and evaluation of providers. (a) A managed care plan shall
18develop a process for selecting participating providers, including written policies and
19procedures that the plan uses for review and approval of providers. After consulting
20with appropriately qualified providers, the plan shall establish minimum
21professional requirements for its participating providers. The process for selection
22shall include verification of a provider's license or certificate, including the history
23of any suspensions or revocations, and the history of any liability claims made
24against the provider.
AB927,18,4
1(b) A managed care plan shall establish in writing a formal, ongoing process
2for reevaluating each participating provider within a specified number of years after
3the provider's initial acceptance for participation. The reevaluation shall include all
4of the following:
AB927,18,55
1. Updating the previous review criteria.
AB927,18,76
2. Assessing the provider's performance on the basis of such criteria as enrollee
7clinical outcomes, number of complaints and malpractice actions.
AB927,18,98
(c) A managed care plan may not require a participating provider to provide
9services that are outside the scope of his or her license or certificate.
AB927, s. 41
10Section
41. 609.34 of the statutes is created to read:
AB927,18,14
11609.34 Clinical decision-making; medical director. A managed care plan
12shall appoint a physician as medical director. The medical director shall be
13responsible for treatment policies, protocols, quality assurance activities and
14utilization management decisions of the plan.
AB927, s. 42
15Section
42. 609.36 of the statutes is created to read:
AB927,18,18
16609.36 Data systems and confidentiality. (1) Information and data
17reporting. (a) A managed care plan shall provide to the commissioner information
18related to all of the following:
AB927,18,1919
1. The structure of the plan.
AB927,18,2020
2. The plan's decision-making process.
AB927,18,2121
3. Health care benefits and exclusions.
AB927,18,2222
4. Cost-sharing requirements.
AB927,18,2323
5. Participating providers.
AB927,18,2524
(b) Subject to sub. (2), the information and data reported under par. (a) shall
25be open to public inspection under ss. 19.31 to 19.39.
AB927,19,3
1(2) Confidentiality. A managed care plan shall establish written policies and
2procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical
3records and enrollee communications to ensure confidentiality.
AB927, s. 43
4Section
43. 609.38 of the statutes is created to read:
AB927,19,8
5609.38 Oversight. The office shall perform examinations of insurers that
6issue managed care plans consistent with ss. 601.43 and 601.44. The commissioner
7shall by rule develop standards for managed care plans for compliance with the
8requirements under this chapter.
AB927, s. 44
9Section
44. 609.65 (1) (intro.) of the statutes is amended to read:
AB927,19,1810
609.65
(1) (intro.) If an
enrolled participant of a health maintenance
11organization, enrollee of a limited service health organization or
preferred provider 12managed care plan is examined, evaluated or treated for a nervous or mental
13disorder pursuant to an emergency detention under s. 51.15, a commitment or a
14court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the
15limitations regarding
selected participating providers, primary providers and
16referrals under ss. 609.01 (2) to (4) and 609.05 (3), the
health maintenance
17organization, limited service health organization or
preferred provider managed
18care plan shall do all of the following:
AB927, s. 45
19Section
45. 609.65 (1) (a) of the statutes is amended to read:
AB927,19,2520
609.65
(1) (a) If the provider performing the examination, evaluation or
21treatment has a provider agreement with the
health maintenance organization,
22limited service health organization or
preferred provider managed care plan which
23covers the provision of that service to the
enrolled participant enrollee, make the
24service available to the
enrolled participant enrollee in accordance with the terms
25of the health care plan and the provider agreement.
AB927, s. 46
1Section
46. 609.65 (1) (b) (intro.) of the statutes is amended to read:
AB927,20,92
609.65
(1) (b) (intro.) If the provider performing the examination, evaluation
3or treatment does not have a provider agreement with the
health maintenance
4organization, limited service health organization or
preferred provider managed
5care plan which covers the provision of that service to the
enrolled participant 6enrollee, reimburse the provider for the examination, evaluation or treatment of the
7enrolled participant enrollee in an amount not to exceed the maximum
8reimbursement for the service under the medical assistance program under subch.
9IV of ch. 49, if any of the following applies:
AB927, s. 47
10Section
47. 609.65 (1) (b) 1. of the statutes is amended to read:
AB927,20,1511
609.65
(1) (b) 1. The service is provided pursuant to a commitment or a court
12order, except that reimbursement is not required under this subdivision if the
health
13maintenance organization, limited service health organization or
preferred provider 14managed care plan could have provided the service through a provider with whom
15it has a provider agreement.
AB927, s. 48
16Section
48. 609.65 (1) (b) 2. of the statutes is amended to read:
AB927,20,2117
609.65
(1) (b) 2. The service is provided pursuant to an emergency detention
18under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20
19and the provider notifies the
health maintenance organization, limited service
20health organization or
preferred provider managed care plan within 72 hours after
21the initial provision of the service.
AB927, s. 49
22Section
49. 609.65 (2) of the statutes is amended to read:
AB927,21,423
609.65
(2) If after receiving notice under sub. (1) (b) 2. the
health maintenance
24organization, limited service health organization or
preferred provider managed
25care plan arranges for services to be provided by a provider with whom it has a
1provider agreement, the
health maintenance organization, limited service health
2organization or
preferred provider managed care plan is not required to reimburse
3a provider under sub. (1) (b) 2. for any services provided after arrangements are made
4under this subsection.
AB927, s. 50
5Section
50. 609.65 (3) of the statutes is amended to read:
AB927,21,156
609.65
(3) A
health maintenance organization, limited service health
7organization or
preferred provider managed care plan is only required to make
8available, or make reimbursement for, an examination, evaluation or treatment
9under sub. (1) to the extent that the
health maintenance organization, limited
10service health organization or
preferred provider
managed care plan would have
11made the medically necessary service available to the
enrolled participant enrollee 12or reimbursed the provider for the service if any referrals required under s. 609.05
13(3) had been made and the service had been performed by a
participating provider
14selected by the health maintenance organization, limited service health
15organization or
preferred provider plan.
AB927, s. 51
16Section
51. 609.655 (1) (a) 1. of the statutes is amended to read:
AB927,21,1917
609.655
(1) (a) 1. Is covered as a dependent child under the terms of a policy
18or certificate issued by a
health maintenance organization managed care plan
19insurer.
AB927, s. 52
20Section
52. 609.655 (1) (a) 2. of the statutes is amended to read:
AB927,21,2321
609.655
(1) (a) 2. Is enrolled in a school located in this state but outside the
22geographical service area of the
health maintenance organization managed care
23plan.
AB927, s. 53
24Section
53. 609.655 (2) of the statutes is amended to read:
AB927,22,9
1609.655
(2) If a policy or certificate issued by a
health maintenance
2organization managed care plan insurer provides coverage of outpatient services
3provided to a dependent student, the policy or certificate shall provide coverage of
4outpatient services, to the extent and in the manner required under sub. (3), that are
5provided to the dependent student while he or she is attending a school located in this
6state but outside the geographical service area of the
health maintenance
7organization managed care plan, notwithstanding the limitations regarding
selected 8participating providers, primary providers and referrals under ss. 609.01 (2) and
9609.05 (3).
AB927, s. 54
10Section
54. 609.655 (3) (intro.) of the statutes is amended to read:
AB927,22,1311
609.655
(3) (intro.) Except as provided in sub. (5), a
health maintenance
12organization managed care plan shall provide coverage for all of the following
13services:
AB927, s. 55
14Section
55. 609.655 (3) (a) of the statutes is amended to read:
AB927,22,2015
609.655
(3) (a) A clinical assessment of the dependent student's nervous or
16mental disorders or alcoholism or other drug abuse problems, conducted by a
17provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in
18reasonably close proximity to the school in which the dependent student is enrolled
19and who may be designated by the
health maintenance organization managed care
20plan.
AB927, s. 56
21Section
56. 609.655 (3) (b) (intro.) of the statutes is amended to read:
AB927,23,222
609.655
(3) (b) (intro.) If outpatient services are recommended in the clinical
23assessment conducted under par. (a), the recommended outpatient services
24consisting of not more than 5 visits to an outpatient treatment facility or other
25provider that is located in this state and in reasonably close proximity to the school
1in which the dependent student is enrolled and that may be designated by the
health
2maintenance organization managed care plan, except as follows:
AB927, s. 57
3Section
57. 609.655 (3) (b) 1. of the statutes is amended to read:
AB927,23,74
609.655
(3) (b) 1. Coverage is not required under this paragraph if the medical
5director of the
health maintenance organization managed care plan determines that
6the nature of the treatment recommended in the clinical assessment will prohibit the
7dependent student from attending school on a regular basis.
AB927, s. 58
8Section
58. 609.655 (4) (a) of the statutes is amended to read:
AB927,23,189
609.655
(4) (a) Upon completion of the 5 visits for outpatient services covered
10under sub. (3) (b), the medical director of the
health maintenance organization 11managed care plan and the clinician treating the dependent student shall review the
12dependent student's condition and determine whether it is appropriate to continue
13treatment of the dependent student's nervous or mental disorders or alcoholism or
14other drug abuse problems in reasonably close proximity to the school in which the
15student is enrolled. The review is not required if the dependent student is no longer
16enrolled in the school or if the coverage limits under the policy or certificate for
17treatment of nervous or mental disorders or alcoholism or other drug abuse problems
18have been exhausted.
AB927, s. 59
19Section
59. 609.655 (4) (b) of the statutes is amended to read:
AB927,24,320
609.655
(4) (b) Upon completion of the review under par. (a), the medical
21director of the
health maintenance organization managed care plan shall determine
22whether the policy or certificate will provide coverage of any further treatment for
23the dependent student's nervous or mental disorder or alcoholism or other drug
24abuse problems that is provided by a provider located in reasonably close proximity
25to the school in which the student is enrolled. If the dependent student disputes the
1medical director's determination, the dependent student may submit a written
2grievance under the
health maintenance organization's
managed care plan's 3internal grievance procedure established under s. 609.15.
AB927, s. 60
4Section
60. 609.655 (5) (a) of the statutes is amended to read:
AB927,24,105
609.655
(5) (a) A policy or certificate issued by a
health maintenance
6organization managed care plan insurer is required to provide coverage for the
7services specified in sub. (3) only to the extent that the policy or certificate would
8have covered the service if it had been provided to the dependent student by a
9selected participating provider within the geographical service area of the
health
10maintenance organization managed care plan.
AB927, s. 61
11Section
61. 609.655 (5) (b) of the statutes is amended to read:
AB927,24,1712
609.655
(5) (b) Paragraph (a) does not permit a
health maintenance
13organization managed care plan to reimburse a provider for less than the full cost
14of the services provided or an amount negotiated with the provider, solely because
15the reimbursement rate for the service would have been less if provided by a
selected 16participating provider within the geographical service area of the
health
17maintenance organization managed care plan.
AB927, s. 62
18Section
62. 609.70 of the statutes is amended to read:
AB927,24,21
19609.70 Chiropractic coverage. Health maintenance organizations, limited
20Limited service health organizations and
preferred provider managed care plans are
21subject to s. 632.87 (3).
AB927, s. 63
22Section
63. 609.75 of the statutes is amended to read:
AB927,25,4
23609.75 Adopted children coverage.
Health maintenance organizations,
24limited Limited service health organizations and
preferred provider managed care 25plans are subject to s. 632.896. Coverage of health care services obtained by adopted
1children and children placed for adoption may be subject to any requirements that
2the
health maintenance organization, limited service health organization or
3preferred provider managed care plan imposes under s. 609.05 (2) and (3) on the
4coverage of health care services obtained by other
enrolled participants enrollees.
AB927,25,9
7609.77 Coverage of breast reconstruction. Health maintenance
8organizations, limited Limited service health organizations and
preferred provider 9managed care plans are subject to s. 632.895 (13).
AB927,25,15
12609.78 Coverage of treatment for the correction of
13temporomandibular disorders. Health maintenance organizations, limited 14Limited service health organizations and
preferred provider managed care plans are
15subject to s. 632.895 (11).
AB927,25,21
18609.79 Coverage of hospital and ambulatory surgery center charges
19and anesthetics for dental care. Health maintenance organizations, limited 20Limited service health organizations and
preferred provider managed care plans are
21subject to s. 632.895 (12).