If a managed care plan limits coverage for experimental treatment, the plan
must disclose who is authorized to make a determination on limiting coverage and
the criteria used to determine whether a treatment, procedure, drug or device is
experimental. The plan must make a coverage decision within 5 days after receiving
a request for prior authorization of an experimental procedure. Whenever coverage
for experimental treatment is denied, the plan must provide the enrollee with a
denial letter that informs the enrollee of who made the coverage decision, the reasons
for the denial and the enrollee's right to appeal the decision.
A managed care plan must establish an internal quality assurance program, a
peer review process and processes for selecting participating providers and
reevaluating those providers after initial acceptance into the plan. A managed care
plan must appoint a physician as medical director to be responsible for the treatment
policies, protocols, quality assurance activities and utilization management
decisions of the plan.
A managed care plan may not penalize or terminate the contract of a
participating provider for discussing with an enrollee financial incentives under the
plan. A managed care plan may not penalize or terminate the contract of a
participating provider for making referrals to other participating providers or for
discussing medically necessary or appropriate care with an enrollee.
For further information see the state and local fiscal estimate, which will be
printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB927, s. 1
1Section
1. 40.51 (12) of the statutes is repealed and recreated to read:
AB927,3,42
40.51
(12) Every managed care plan, as defined in s. 609.01 (3c), and every
3limited service health organization, as defined in s. 609.01 (3), that is offered by the
4state under sub. (6) shall comply with ch. 609.
AB927, s. 2
5Section
2. 40.51 (13) of the statutes is created to read:
AB927,4,3
140.51
(13) Every managed care plan, as defined in s. 609.01 (3c), and every
2limited service health organization, as defined in s. 609.01 (3), that is offered by the
3group insurance board under sub. (7) shall comply with ch. 609.
AB927, s. 3
4Section
3. 51.20 (7) (am) of the statutes is amended to read:
AB927,4,115
51.20
(7) (am) A subject individual may not be examined, evaluated or treated
6for a nervous or mental disorder pursuant to a court order under this subsection
7unless the court first attempts to determine whether the person is an
enrolled
8participant enrollee of a health maintenance organization, limited service health
9organization or preferred provider plan, as defined in s. 609.01, and, if so, notifies the
10organization or plan that the subject individual is in need of examination, evaluation
11or treatment for a nervous or mental disorder.
AB927, s. 4
12Section
4. 601.42 (1g) (d) of the statutes is amended to read:
AB927,4,1813
601.42
(1g) (d) Statements, reports, answers to questionnaires or other
14information, or reports, audits or certification from a certified public accountant or
15an actuary approved by the commissioner, relating to the extent liabilities of a health
16maintenance organization insurer are or will be
covered liabilities, as defined in s.
17609.01 (1) liabilities for health care costs for which an enrollee or policyholder of the
18health maintenance organization is not liable to any person under s. 609.91.
AB927, s. 5
19Section
5. Chapter 609 (title) of the statutes is repealed and recreated to read:
AB927,4,2120
Chapter 609
21
managed care plans
AB927, s. 6
22Section
6. 609.01 (1) of the statutes is repealed.
AB927, s. 7
23Section
7. 609.01 (1c) of the statutes is created to read:
AB927,5,324
609.01
(1c) "Emergency medical condition" means a medical condition that
25manifests itself by acute symptoms of sufficient severity, including severe pain, to
1lead a prudent layperson who possesses an average knowledge of health and
2medicine to reasonably conclude that a lack of immediate medical attention might
3result in any of the following:
AB927,5,44
(a) Serious jeopardy to the person's health.
AB927,5,55
(b) Serious impairment to the person's bodily functions.
AB927,5,66
(c) Serious dysfunction of any of the person's bodily organs or parts.
AB927, s. 8
7Section
8. 609.01 (1d) of the statutes is repealed and recreated to read:
AB927,5,108
609.01
(1d) "Enrollee" means, with respect to a managed care plan or limited
9service health organization, a person who is entitled to receive health care services
10under the plan.
AB927, s. 9
11Section
9. 609.01 (1g) of the statutes is created to read:
AB927,5,1312
609.01
(1g) (a) Except as provided in par. (b), "health benefit plan" means any
13hospital or medical policy or certificate.
AB927,5,1414
(b) "Health benefit plan" does not include any of the following:
AB927,5,1615
1. Coverage that is only accident or disability income insurance, or any
16combination of the 2 types.
AB927,5,1717
2. Coverage issued as a supplement to liability insurance.
AB927,5,1918
3. Liability insurance, including general liability insurance and automobile
19liability insurance.
AB927,5,2020
4. Worker's compensation or similar insurance.
AB927,5,2121
5. Automobile medical payment insurance.
AB927,5,2222
6. Credit-only insurance.
AB927,5,2323
7. Coverage for on-site medical clinics.
AB927,6,3
18. Other similar insurance coverage, as specified in regulations issued by the
2federal department of health and human services, under which benefits for medical
3care are secondary or incidental to other insurance benefits.
AB927,6,94
9. If provided under a separate policy, certificate or contract of insurance, or if
5otherwise not an integral part of the policy, certificate or contract of insurance:
6limited-scope dental or vision benefits; benefits for long-term care, nursing home
7care, home health care, community-based care, or any combination of those benefits;
8and such other similar, limited benefits as are specified in regulations issued by the
9federal department of health and human services under section 2791 of P.L.
104-191.
AB927,6,1110
10. Hospital indemnity or other fixed indemnity insurance or coverage only for
11a specified disease or illness, if all of the following apply:
AB927,6,1312
a. The benefits are provided under a separate policy, certificate or contract of
13insurance.
AB927,6,1614
b. There is no coordination between the provision of such benefits and any
15exclusion of benefits under any group health plan maintained by the same plan
16sponsor.
AB927,6,1917
c. Such benefits are paid with respect to an event without regard to whether
18benefits are provided with respect to such an event under any group health plan
19maintained by the same plan sponsor.
AB927,6,2020
11. Other insurance exempted by rule of the commissioner.
AB927, s. 10
21Section
10. 609.01 (1p) of the statutes is created to read:
AB927,6,2522
609.01
(1p) "Health care professional" means any individual licensed,
23registered, permitted or certified by the department of health and family services or
24the department of regulation and licensing to provide health care services, items or
25supplies in this state.
AB927, s. 11
1Section
11. 609.01 (2) of the statutes is amended to read:
AB927,7,72
609.01
(2) "Health maintenance organization" means a health care plan
3offered by an organization established under ch. 185, 611, 613 or 614 or issued a
4certificate of authority under ch. 618 that makes available to its
enrolled
5participants enrollees, in consideration for predetermined periodic fixed payments,
6comprehensive health care services performed by providers
selected by the
7organization participating in the plan.
AB927, s. 12
8Section
12. 609.01 (3) of the statutes is amended to read:
AB927,7,149
609.01
(3) "Limited service health organization" means a health care plan
10offered by an organization established under ch. 185, 611, 613 or 614 or issued a
11certificate of authority under ch. 618 that makes available to its
enrolled
12participants enrollees, in consideration for predetermined periodic fixed payments,
13a limited range of health care services performed by providers
selected by the
14organization participating in the plan.
AB927, s. 13
15Section
13. 609.01 (3c) of the statutes is created to read:
AB927,7,2116
609.01
(3c) "Managed care plan" means a health benefit plan that requires an
17enrollee of the health benefit plan, or creates incentives, including financial
18incentives, for an enrollee of the health benefit plan, to use providers that are
19managed, owned, under contract with or employed by the insurer offering the health
20benefit plan. The term includes a health maintenance organization and a preferred
21provider plan, but does not include a limited service health organization.
AB927, s. 14
22Section
14. 609.01 (3m) of the statutes is created to read:
AB927,8,223
609.01
(3m) "Participating" means, with respect to a physician or other
24provider, under contract with a managed care plan or limited service health
1organization to provide health care services, items or supplies to enrollees of the
2plan.
AB927, s. 15
3Section
15. 609.01 (3r) of the statutes is created to read:
AB927,8,44
609.01
(3r) "Physician" has the meaning given in s. 448.01 (5).
AB927, s. 16
5Section
16. 609.01 (4) of the statutes is amended to read:
AB927,8,116
609.01
(4) "Preferred provider plan" means a health care plan offered by an
7organization established under ch. 185, 611, 613 or 614 or issued a certificate of
8authority under ch. 618 that makes available to its
enrolled participants enrollees,
9for consideration other than predetermined periodic fixed payments, either
10comprehensive health care services or a limited range of health care services
11performed by providers
selected by the organization
participating in the plan.
AB927, s. 17
12Section
17. 609.01 (4m) of the statutes is created to read:
AB927,8,1413
609.01
(4m) "Primary care physician" means a physician specializing in family
14medical practice, general internal medicine, obstetrics and gynecology or pediatrics.
AB927, s. 18
15Section
18. 609.01 (5) of the statutes is repealed and recreated to read:
AB927,8,1716
609.01
(5) "Primary provider" means a participating health care professional
17who coordinates, supervises and may provide ongoing care to an enrollee.
AB927, s. 19
18Section
19. 609.01 (6) of the statutes is repealed and recreated to read:
AB927,8,2019
609.01
(6) "Specialist physician" means a physician who is not a primary care
20physician.
AB927, s. 20
21Section
20. 609.01 (7) of the statutes is amended to read:
AB927,8,2322
609.01
(7) "Standard plan" means a health care plan
other than a health
23maintenance organization or a preferred provider that is not a managed care plan.
AB927, s. 21
24Section
21. 609.05 (1) of the statutes is amended to read:
AB927,9,4
1609.05
(1) Except as provided in subs. (2) and (3), a
health maintenance
2organization, limited service health organization or
preferred provider managed
3care plan shall permit its
enrolled participants
enrollees to choose freely among
4selected participating providers.
AB927, s. 22
5Section
22. 609.05 (2) of the statutes is amended to read:
AB927,9,86
609.05
(2) A Subject to s. 609.22 (4), a health care plan under sub. (1) may
7require an
enrolled participant enrollee to designate a primary provider and to
8obtain health care services from the primary provider when reasonably possible.
AB927, s. 23
9Section
23. 609.05 (3) of the statutes is amended to read:
AB927,9,1410
609.05
(3) Except as provided in ss. 609.65 and 609.655, a health care plan
11under sub. (1) may require an
enrolled participant
enrollee to obtain a referral from
12the primary provider designated under sub. (2) to another
selected participating 13provider prior to obtaining health care services from
the other selected that
14participating provider.
AB927, s. 24
15Section
24. 609.10 (1) (a) of the statutes is amended to read:
AB927,9,2116
609.10
(1) (a) Except as provided in subs. (2) to (4), an employer that offers any
17of its employes a health maintenance organization or a preferred provider plan that
18provides comprehensive health care services shall also offer the employes a standard
19plan, as provided in pars. (b) and (c), that provides at least substantially equivalent
20coverage of health care expenses
and that is not a health maintenance organization
21or a preferred provider plan.
AB927, s. 25
22Section
25. 609.15 (1) (intro.) of the statutes is amended to read:
AB927,9,2523
609.15
(1) (intro.) Each
health maintenance organization, limited service
24health organization and
preferred provider managed care plan shall do all of the
25following:
AB927, s. 26
1Section
26. 609.15 (1) (a) of the statutes is amended to read:
AB927,10,42
609.15
(1) (a) Establish and use an internal grievance procedure that is
3approved by the commissioner and that complies with sub. (2) for the resolution of
4enrolled participants' enrollees' grievances with the health care plan.
AB927, s. 27
5Section
27. 609.15 (1) (b) of the statutes is amended to read:
AB927,10,86
609.15
(1) (b) Provide
enrolled participants enrollees with complete and
7understandable information describing the internal grievance procedure under par.
8(a).
AB927, s. 28
9Section
28. 609.15 (2) (a) of the statutes is amended to read:
AB927,10,1110
609.15
(2) (a) The opportunity for an
enrolled participant enrollee to submit
11a written grievance in any form.
AB927, s. 29
12Section
29. 609.15 (2) (b) of the statutes is amended to read:
AB927,10,1713
609.15
(2) (b) Establishment of a grievance panel for the investigation of each
14grievance submitted under par. (a), consisting of at least one individual authorized
15to take corrective action on the grievance and at least one
enrolled participant 16enrollee other than the grievant, if an
enrolled participant enrollee is available to
17serve on the grievance panel.
AB927, s. 30
18Section
30. 609.17 of the statutes is amended to read:
AB927,10,24
19609.17 Reports of disciplinary action. Every
health maintenance
20organization, limited service health organization and
preferred provider managed
21care plan shall notify the medical examining board or appropriate affiliated
22credentialing board attached to the medical examining board of any disciplinary
23action taken against a
selected participating provider who holds a license or
24certificate granted by the board or affiliated credentialing board.
AB927, s. 31
25Section
31. 609.20 (intro.) of the statutes is amended to read:
AB927,11,3
1609.20 Rules for preferred provider managed care plans. (intro.) The
2commissioner shall promulgate rules
applicable to preferred provider plans relating
3to managed care plans for all of the following purposes:
AB927, s. 32
4Section
32. 609.20 (1) of the statutes is amended to read:
AB927,11,65
609.20
(1) To ensure that
enrolled participants enrollees are not forced to travel
6excessive distances to receive health care services.
AB927, s. 33
7Section
33. 609.20 (2) of the statutes is amended to read:
AB927,11,98
609.20
(2) To ensure that the continuity of patient care for
enrolled participants 9enrollees is not disrupted.