AB1052: Bill Text

AB1052,6,22 (2) Preferred provider plans. A preferred provider plan shall include in its provider directory, in substantially similar language, the following notice:

AB1052,6,23 IMPORTANT NOTICE

AB1052,7,10 You are strongly encouraged to contact us to verify the status of the providers involved in your care including, for example, the anesthesiologist, radiologist, pathologist, facility, clinic, or laboratory, when scheduling appointments or elective procedures to determine whether each provider is a participating or nonparticipating provider. Such information may assist you in your selection of providers and will likely affect the level of copayment, deductible, and coinsurance applicable to the care you receive. The information contained in this directory may change during your plan year. Please contact [insert phone number of insurer] to learn more about the participating providers in your network and the implications, including financial, if you decide to receive your care from nonparticipating providers.

AB1052, s. 14 Section 14. 609.35 of the statutes is renumbered 609.35 (2).

AB1052, s. 15 Section 15. 609.35 (1) of the statutes is created to read:

AB1052,7,15 609.35 (1) In this section, a preferred provider plan covers the same service when performed by a nonparticipating provider that it covers when performed by a participating provider, if any of the following applies:

AB1052,7,17 (a) The coinsurance differential between a participating and a nonparticipating provider paid by an enrollee for the service is 40 percent or less.

AB1052,7,19 (b) Coinsurance paid by an enrollee for the service when performed by a nonparticipating provider is 50 percent or less.

AB1052, s. 16 Section 16. 609.82 of the statutes is renumbered 609.82 (1).

AB1052, s. 17 Section 17. 609.82 (2) of the statutes is created to read:

AB1052,8,2 609.82 (2) (a) Except as provided in pars. (b) and (c), if a preferred provider plan provides coverage of emergency medical services, the preferred provider plan shall cover emergency medical services provided to an enrollee during the treatment of an emergency medical condition, as defined in s. 632.85 (1) (a), by a nonparticipating provider as though the services were provided by a participating provider, if any of the following applies:

AB1052,8,4 1. The enrollee could not reasonably reach a participating provider for treatment of the emergency medical condition.

AB1052,8,6 2. As a result of the emergency, the enrollee was admitted to a nonparticipating provider for inpatient care.

AB1052,8,11 (b) The coverage under par. (a) may be subject to any restrictions that govern payment to a participating provider for emergency medical services. The preferred provider plan shall pay the nonparticipating provider at the rate at which it pays a nonparticipating provider, after applying any copayments, deductibles, or other cost-sharing requirements that apply to a participating provider.

AB1052,8,14 (c) A preferred provider plan is required to provide the coverage under par. (a) only with respect to services that are needed to stabilize, as defined in section 1867 of the federal Social Security Act, the enrollee's emergency medical condition.

AB1052, s. 18 Section 18. 611.67 (1) (d) of the statutes is repealed.

AB1052, s. 19 Section 19. 628.36 (2m) (a) 3. of the statutes is repealed.

AB1052, s. 20 Section 20. 632.745 (15) of the statutes is amended to read:

AB1052,8,24 632.745 (15) "Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers health benefit plans covering individuals in this state or eligible employees of one or more employers in this state. The term includes a health maintenance organization, a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a cooperative association organized under ss. 185.981 to 185.985 and a limited service health organization, as defined in s. 609.01 (3).

AB1052, s. 21 Section 21. 632.84 (3) of the statutes is amended to read:

AB1052,9,3 632.84 (3) Exceptions. This section does not apply to a health maintenance organization, as defined in s. 609.01 (2), limited service health organization, as defined in s. 609.01 (3), or preferred provider plan, as defined in s. 609.01.

AB1052, s. 22 Section 22. 632.86 (1) (a) of the statutes is amended to read:

AB1052,9,10 632.86 (1) (a) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a), except that the term does not include coverage under a health maintenance organization, as defined in s. 609.01 (2), a limited service health organization, as defined in s. 609.01 (3), a preferred provider plan, as defined in s. 609.01 (4), or a sickness care plan operated by a cooperative association organized under ss. 185.981 to 185.985.

AB1052, s. 23 Section 23. 632.895 (14) (d) 3. of the statutes is amended to read:

AB1052,9,14 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB1052, s. 24 Section 24. 635.02 (8) of the statutes is amended to read:

AB1052,9,24 635.02 (8) "Small employer insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that offers group health benefit plans covering eligible employees of one or more small employers in this state, or that sells 3 or more individual health benefit plans to a small employer, covering eligible employees of the small employer. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a cooperative association organized under ss. 185.981 to 185.985, but does not include a limited service health organization, as defined in s. 609.01 (3).

AB1052, s. 25 Section 25. Initial applicability.

AB1052,10,3 (1) Coverage of same services and emergency medical services. The renumbering of sections 609.35 and 609.82 of the statutes and the creation of sections 609.35 (1) and 609.82 (2) of the statutes first apply to all of the following:

AB1052,10,5 (a) Except as provided in paragraph (b), policies, plans, or contracts that are issued or renewed on the effective date of this paragraph.

AB1052,10,10 (b) Policies, plans, or contracts covering employees who are affected by a collective bargaining agreement containing provisions inconsistent with the renumbering of sections 609.35 and 609.82 of the statutes and the creation of sections 609.35 (1) and 609.82 (2) of the statutes that are issued or renewed on the earlier of the following:

AB1052,10,11 1. The day on which the collective bargaining agreement expires.

AB1052,10,13 2. The day on which the collective bargaining agreement is extended, modified, or renewed.

AB1052,10,20 (2) Access standards for preferred provider plans. If an insurance policy, plan, or certificate that is issued by a preferred provider plan and that is in effect on the effective date of this subsection, or a contract that is in effect on the effective date of this subsection between a provider and a preferred provider plan, contains a provision that is inconsistent with the treatment of section 609.22 (1m) (a) of the statutes, the treatment of section 609.22 (1m) (a) of the statutes first applies to that policy, plan, certificate, or contract on the date on which it is renewed.

AB1052,11,2 (3) Prior authorization requirements. If an insurance policy, plan, or certificate that is issued by a preferred provider plan and that is in effect on the effective date of this subsection, or a contract that is in effect on the effective date of this subsection between a provider and a preferred provider plan, contains a provision that is inconsistent with the treatment of section 609.22 (9) of the statutes, the treatment of section 609.22 (9) of the statutes first applies to that policy, plan, certificate, or contract on the date on which it is renewed.

AB1052,11,3 (End)