SB380, s. 44
4Section
44. 609.65 (1) (b) (intro.) of the statutes is amended to read:
SB380,18,125
609.65
(1) (b) (intro.) If the provider performing the examination, evaluation
6or treatment does not have a provider agreement with the
health maintenance
7organization, limited service health organization or preferred provider managed
8care plan which covers the provision of that service to the
enrolled participant 9enrollee, reimburse the provider for the examination, evaluation or treatment of the
10enrolled participant enrollee in an amount not to exceed the maximum
11reimbursement for the service under the medical assistance program under subch.
12IV of ch. 49, if any of the following applies:
SB380, s. 45
13Section
45. 609.65 (1) (b) 1. of the statutes is amended to read:
SB380,18,1814
609.65
(1) (b) 1. The service is provided pursuant to a commitment or a court
15order, except that reimbursement is not required under this subdivision if the
health
16maintenance organization, limited service health organization or preferred provider 17managed care plan could have provided the service through a provider with whom
18it has a provider agreement.
SB380, s. 46
19Section
46. 609.65 (1) (b) 2. of the statutes is amended to read:
SB380,18,2420
609.65
(1) (b) 2. The service is provided pursuant to an emergency detention
21under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20
22and the provider notifies the
health maintenance organization, limited service
23health organization or preferred provider managed care plan within 72 hours after
24the initial provision of the service.
SB380, s. 47
25Section
47. 609.65 (2) of the statutes is amended to read:
SB380,19,7
1609.65
(2) If after receiving notice under sub. (1) (b) 2. the
health maintenance
2organization, limited service health organization or preferred provider managed
3care plan arranges for services to be provided by a provider with whom it has a
4provider agreement, the
health maintenance organization, limited service health
5organization or preferred provider managed care plan is not required to reimburse
6a provider under sub. (1) (b) 2. for any services provided after arrangements are made
7under this subsection.
SB380, s. 48
8Section
48. 609.65 (3) of the statutes is amended to read:
SB380,19,189
609.65
(3) A
health maintenance organization, limited service health
10organization or preferred provider managed care plan is only required to make
11available, or make reimbursement for, an examination, evaluation or treatment
12under sub. (1) to the extent that the
health maintenance organization, limited
13service health organization or preferred provider managed care plan would have
14made the medically necessary service available to the
enrolled participant enrollee 15or reimbursed the provider for the service if any referrals required under s. 609.05
16(3) had been made and the service had been performed by a
participating provider
17selected by the health maintenance organization, limited service health
18organization or preferred provider plan.
SB380, s. 49
19Section
49. 609.655 (2) of the statutes is amended to read:
SB380,20,220
609.655
(2) If a policy or certificate issued by a health maintenance
21organization provides coverage of outpatient services provided to a dependent
22student, the policy or certificate shall provide coverage of outpatient services, to the
23extent and in the manner required under sub. (3), that are provided to the dependent
24student while he or she is attending a school located in this state but outside the
25geographical service area of the health maintenance organization, notwithstanding
1the limitations regarding
selected participating providers, primary providers and
2referrals under ss. 609.01 (2) and 609.05 (3).
SB380, s. 50
3Section
50. 609.655 (5) (a) of the statutes is amended to read:
SB380,20,84
609.655
(5) (a) A policy or certificate issued by a health maintenance
5organization is required to provide coverage for the services specified in sub. (3) only
6to the extent that the policy or certificate would have covered the service if it had been
7provided to the dependent student by a
selected participating provider within the
8geographical service area of the health maintenance organization.
SB380, s. 51
9Section
51. 609.655 (5) (b) of the statutes is amended to read:
SB380,20,1510
609.655
(5) (b) Paragraph (a) does not permit a health maintenance
11organization to reimburse a provider for less than the full cost of the services
12provided or an amount negotiated with the provider, solely because the
13reimbursement rate for the service would have been less if provided by a
selected 14participating provider within the geographical service area of the health
15maintenance organization.
SB380, s. 52
16Section
52. 609.70 of the statutes is amended to read:
SB380,20,19
17609.70 Chiropractic coverage. Health maintenance organizations, limited
18service health organizations and preferred provider Managed care plans are subject
19to s. 632.87 (3).
SB380, s. 53
20Section
53. 609.75 of the statutes is amended to read:
SB380,21,2
21609.75 Adopted children coverage.
Health maintenance organizations,
22limited service health organizations and preferred provider Managed care plans are
23subject to s. 632.896. Coverage of health care services obtained by adopted children
24and children placed for adoption may be subject to any requirements that the
health
25maintenance organization, limited service health organization or preferred provider
1managed care plan imposes under s. 609.05 (2) and (3) on the coverage of health care
2services obtained by other
enrolled participants
enrollees.
SB380, s. 54
3Section
54. 609.80 of the statutes is amended to read:
SB380,21,8
4609.80 Coverage of mammograms. Health maintenance organizations and
5preferred provider plans are subject to s. 632.895 (8). Coverage of mammograms
6under s. 632.895 (8) may be subject to any requirements that the health maintenance
7organization or preferred provider plan imposes under s. 609.05 (2) and (3) on the
8coverage of other health care services obtained by
enrolled participants enrollees.
SB380, s. 55
9Section
55. 609.81 of the statutes is amended to read:
SB380,21,13
10609.81 Coverage related to HIV infection. Health maintenance
11organizations, limited service health organizations and preferred provider Managed
12care plans are subject to s. 631.93. Health maintenance organizations and preferred
13provider plans are subject to s. 632.895 (9).
SB380, s. 56
14Section
56. 609.91 (1) (intro.) of the statutes is amended to read:
SB380,21,2015
609.91
(1) (title)
Immunity of enrolled participants enrollees and
16policyholders. (intro.) Except as provided in sub. (1m), an
enrolled participant 17enrollee or policyholder of a health maintenance organization insurer is not liable for
18health care costs that are incurred on or after January 1, 1990, and that are covered
19under a policy or certificate issued by the health maintenance organization insurer,
20if any of the following applies:
SB380, s. 57
21Section
57. 609.91 (1) (b) 2. of the statutes is amended to read:
SB380,21,2422
609.91
(1) (b) 2. Is physician services provided under a contract with the health
23maintenance organization insurer or by a
selected
participating provider of the
24health maintenance organization insurer.
SB380, s. 58
25Section
58. 609.91 (1) (b) 3. of the statutes is amended to read:
SB380,22,3
1609.91
(1) (b) 3. Is services, equipment, supplies or drugs that are ancillary or
2incidental to services described in subd. 2. and are provided by the contracting
3provider or
selected participating provider.
SB380, s. 59
4Section
59. 609.91 (1m) of the statutes is amended to read:
SB380,22,95
609.91
(1m) Immunity of medical assistance recipients. An
enrolled
6participant enrollee, policyholder or insured under a policy issued by an insurer to
7the department of health and family services under s. 49.45 (2) (b) 2. to provide
8prepaid health care to medical assistance recipients is not liable for health care costs
9that are covered under the policy.
SB380, s. 60
10Section
60. 609.91 (2) of the statutes is amended to read:
SB380,22,1611
609.91
(2) Prohibited recovery attempts. No person may bill, charge, collect
12a deposit from, seek remuneration or compensation from, file or threaten to file with
13a credit reporting agency or have any recourse against an
enrolled participant 14enrollee, policyholder or insured, or any person acting on their behalf, for health care
15costs for which the
enrolled participant enrollee, policyholder or insured, or person
16acting on their behalf, is not liable under sub. (1) or (1m).
SB380, s. 61
17Section
61. 609.91 (3) of the statutes is amended to read:
SB380,22,2218
609.91
(3) Deductibles, copayments and premiums. Subsections (1) to (2) do not
19affect the liability of an
enrolled participant enrollee, policyholder or insured for any
20deductibles, copayments or premiums owed under the policy or certificate issued by
21the health maintenance organization insurer or by the insurer described in sub.
22(1m).
SB380, s. 62
23Section
62. 609.91 (4) (intro.) of the statutes is amended to read:
SB380,23,224
609.91
(4) (intro.)
Conditions not affecting the immunity. The immunity of
25an
enrolled participant enrollee, policyholder or insured for health care costs, to the
1extent of the immunity provided under this section and ss. 609.92 to 609.935, is not
2affected by any of the following:
SB380, s. 63
3Section
63. 609.91 (4) (a) of the statutes is amended to read:
SB380,23,94
609.91
(4) (a) An agreement, other than a notice of election or termination of
5election in accordance with s. 609.92 or 609.925, entered into by the provider, the
6health maintenance organization insurer, the insurer described in sub. (1m) or any
7other person, at any time, whether oral or written and whether implied or explicit,
8including an agreement that purports to hold the
enrolled participant enrollee,
9policyholder or insured liable for health care costs.
SB380, s. 64
10Section
64. 609.91 (4) (b) of the statutes is amended to read:
SB380,23,1511
609.91
(4) (b) A breach of or default on an agreement by the health
12maintenance organization insurer, the insurer described in sub. (1m) or any other
13person to compensate the provider, directly or indirectly, for health care costs,
14including health care costs for which the
enrolled participant enrollee, policyholder
15or insured is not liable under sub. (1) or (1m).
SB380, s. 65
16Section
65. 609.91 (4) (c) of the statutes is amended to read:
SB380,23,2517
609.91
(4) (c) The insolvency of the health maintenance organization insurer
18or any person contracting with the health maintenance organization insurer or
19provider, or the commencement or the existence of conditions permitting the
20commencement of insolvency, delinquency or bankruptcy proceedings involving the
21health maintenance organization insurer or other person, including delinquency
22proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the health
23maintenance organization insurer or other person has agreed to compensate,
24directly or indirectly, the provider for health care costs for which the
enrolled
25participant enrollee or policyholder is not liable under sub. (1).
SB380, s. 66
1Section
66. 609.91 (4) (cm) of the statutes is amended to read:
SB380,24,92
609.91
(4) (cm) The insolvency of the insurer described in sub. (1m) or any
3person contracting with the insurer or provider, or the commencement or the
4existence of conditions permitting the commencement of insolvency, delinquency or
5bankruptcy proceedings involving the insurer or other person, including
6delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite
7whether the insurer or other person has agreed to compensate, directly or indirectly,
8the provider for health care costs for which the
enrolled participant enrollee,
9policyholder or insured is not liable under sub. (1m).
SB380, s. 67
10Section
67. 609.91 (4) (d) of the statutes is amended to read:
SB380,24,1511
609.91
(4) (d) The inability of the provider or other person who is owed
12compensation for health care costs to obtain compensation from the health
13maintenance organization insurer, the insurer described in sub. (1m) or any other
14person for health care costs for which the
enrolled participant enrollee, policyholder
15or insured is not liable under sub. (1) or (1m).
SB380, s. 68
16Section
68. 609.92 (5) of the statutes is amended to read:
SB380,24,2117
609.92
(5) Provider of physician services. A provider who is not under
18contract with a health maintenance organization insurer and who is not a
selected 19participating provider of a health maintenance organization insurer is not subject
20to s. 609.91 (1) (b) 2. with respect to health care costs incurred by an
enrolled
21participant enrollee of that health maintenance organization insurer.
SB380, s. 69
22Section
69. 609.94 (1) (b) of the statutes is amended to read:
SB380,24,2523
609.94
(1) (b) Each
selected participating provider of the health maintenance
24organization insurer, at the time that the provider becomes a
selected participating 25provider.
SB380, s. 70
1Section
70. 645.69 (1) of the statutes is amended to read:
SB380,25,62
645.69
(1) A claim against a health maintenance organization insurer or an
3insurer described in s. 609.91 (1m) for health care costs, as defined in s. 609.01 (1j),
4for which an
enrolled participant enrollee, as defined in s. 609.01 (1d), policyholder
5or insured of the health maintenance organization insurer or other insurer is not
6liable under ss. 609.91 to 609.935.
SB380, s. 71
7Section
71. 645.69 (2) of the statutes is amended to read:
SB380,25,118
645.69
(2) A claim for health care costs, as defined in s. 609.01 (1j), for which
9an
enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a
10health maintenance organization managed care plan, as defined in s. 609.01 (3c), is
11not liable for any reason.
SB380, s. 72
12Section
72. 646.31 (1) (d) 8. of the statutes is amended to read:
SB380,25,1513
646.31
(1) (d) 8. Made for health care costs, as defined in s. 609.01 (1j), for which
14an
enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a
15health maintenance organization insurer is not liable under ss. 609.91 to 609.935.
SB380, s. 73
16Section
73. 646.31 (1) (d) 9. of the statutes is amended to read:
SB380,25,2017
646.31
(1) (d) 9. Made for health care costs, as defined in s. 609.01 (1j), for which
18an
enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a
19health maintenance organization managed care plan, as defined in s. 609.01 (3c), is
20not liable for any reason.
SB380,25,2522
(1)
If a contract that is in effect on January 1, 1999, that is affected by this act
23and that was not issued or renewed after the effective date of this subsection contains
24terms or provisions that are inconsistent with the requirements under this act, this
25act first applies to that contract upon renewal.
SB380,26,5
1(2) If a contract that is in effect on January 1, 1999, that is affected by this act
2and that is affected by a collective bargaining agreement that was not extended,
3modified or renewed after the effective date of this subsection contains terms or
4provisions that are inconsistent with this act, this act first applies to that contract
5on the earlier of the following:
SB380,26,66
(a) The day on which the collective bargaining agreement expires.
SB380,26,87
(b) The day on which the collective bargaining agreement is extended, modified
8or renewed.
SB380, s. 75
9Section
75.
Effective dates. This act takes effect on January 1, 1999, or on
10the day after publication, whichever is later, except as follows:
SB380,26,1111
(1)
Section
74
of this act takes effect on the day after publication.