2005 - 2006 LEGISLATURE
February 20, 2006 - Introduced by Representative Nischke, cosponsored by
Senator Kapanke. Referred to Committee on Insurance.
AB1052,1,11 1An Act to repeal 611.67 (1) (d) and 628.36 (2m) (a) 3.; to renumber 609.35 and
2609.82; to renumber and amend 609.01 (4); to amend 51.20 (7) (am), 149.10
3(8m), 150.84 (5), 600.03 (23g) (a), 601.47 (3), 632.745 (15), 632.84 (3), 632.86 (1)
4(a), 632.895 (14) (d) 3. and 635.02 (8); and to create 601.47 (2m), 609.01 (4g),
5609.20 (3), 609.20 (4), 609.22 (1m), 609.22 (9), 609.23, 609.35 (1) and 609.82 (2)
6of the statutes; relating to: prohibiting certain rules related to defined
7network plans and preferred provider plans, requiring defined network plans
8and preferred provider plans to provide certain notices, requiring the
9commissioner of insurance to publish a guide describing out-of-network
10coverage for all defined network plans, and other miscellaneous provisions
11related to preferred provider plans.
Analysis by the Legislative Reference Bureau
Current law contains various provisions that apply specifically to defined
network plans and preferred provider plans. A defined network plan is a hospital
or medical policy or certificate that requires, or provides incentives for, enrollees to
obtain health care services from providers that are managed, owned, under contract

with, or employed by the insurer offering the policy or certificate (participating
providers). Specifically excluded, however, are limited-scope dental or vision plans.
A health maintenance organization is an example of a defined network plan. A
preferred provider plan, which covers either comprehensive or limited health care
services provided by either participating or nonparticipating providers, is also a
defined network plan, except for one that is a limited-scope dental or vision plan,
because obtaining services from participating providers usually requires lower
levels of cost-sharing than obtaining services from nonparticipating providers. This
bill makes various changes relating to defined network plans and preferred provider
plans, including the following:
1. Changes the definition of a preferred provider plan so that the requirements
pertaining to preferred provider plans do not apply to preferred provider plans that
are limited-scope dental or vision plans.
2. Prohibits the commissioner of insurance (commissioner) from promulgating
a rule that regulates contracts between a preferred provider plan and its
participating providers or that establishes limits or levels for copayments,
deductibles, or penalties imposed by preferred provider plans.
3. Clarifies that a preferred provider plan covers the same service when it is
performed by a nonparticipating provider that the plan covers when the service is
performed by a participating provider if either the coinsurance differential paid by
an enrollee is 40 percent or less or the coinsurance paid by an enrollee is 50 percent
or less.
4. Establishes that preferred provider plans have complied with certain access
requirements if the number of primary care providers available is consistent with
normal practices and standards in the geographic area and if each female enrollee
has access to at least one primary care provider who provides obstetric and
gynecologic services and prohibits additional requirements by rule.
5. Requires a defined network plan to include a notice in its marketing
materials to alert a prospective enrollee that benefits may be reduced when services
are obtained from a nonparticipating provider and prohibits the commissioner from
promulgating rules that require additional notice about nonparticipating provider
limitations.
6. Requires a preferred provider plan to include in its provider directory a
notice that encourages an enrollee to contact the preferred provider plan to verify
whether a provider involved in his or her care is a participating or nonparticipating
provider, since that may affect the enrollee's level of cost-sharing.
7. Requires the commissioner to publish and distribute a guide that describes
out-of-network coverage for all defined network plans.
8. Prohibits a preferred provider plan from using utilization management
techniques, including prior authorization requirements, to deny access to
nonparticipating providers.
9. Generally, requires a preferred provider plan that covers emergency services
to cover treatment of an emergency medical condition by a nonparticipating provider
as though the services were provided by a participating provider if: a) the enrollee
could not reasonably reach a participating provider for the treatment; or b) as a

result of the emergency, the enrollee was admitted to a nonparticipating provider for
inpatient care.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB1052, s. 1 1Section 1. 51.20 (7) (am) of the statutes is amended to read:
AB1052,3,92 51.20 (7) (am) A subject individual may not be examined, evaluated or treated
3for a nervous or mental disorder pursuant to a court order under this subsection
4unless the court first attempts to determine whether the person is an enrollee of a
5health maintenance organization, as defined in s. 609.01 (2), limited service health
6organization, as defined in s. 609.01 (3), or preferred provider plan, as defined in s.
7609.01 600.03 (37m), and, if so, notifies the organization or plan that the subject
8individual is in need of examination, evaluation or treatment for a nervous or mental
9disorder.
AB1052, s. 2 10Section 2. 149.10 (8m) of the statutes is amended to read:
AB1052,3,1211 149.10 (8m) "Preferred provider plan" has the meaning given in s. 609.01 (4)
12600.03 (37m).
AB1052, s. 3 13Section 3. 150.84 (5) of the statutes is amended to read:
AB1052,3,1514 150.84 (5) "Preferred provider plan" has the meaning given in s. 609.01 (4)
15600.03 (37m).
AB1052, s. 4 16Section 4. 600.03 (23g) (a) of the statutes is amended to read:
AB1052,3,1917 600.03 (23g) (a) Contracts with a health maintenance organization, as defined
18in s. 609.01 (2),
limited service health organization, as defined in s. 609.01 (3), or
19preferred provider plan, as defined in s. 609.01, to provide health care services.
AB1052, s. 5 20Section 5. 601.47 (2m) of the statutes is created to read:
AB1052,4,4
1601.47 (2m) The commissioner shall prepare and publish a guide that
2describes out-of-network coverage for all defined network plans and distribute it in
3a manner that the commissioner determines. The cost of publication and
4distribution may be paid from the appropriation under s. 20.145 (1) (g).
AB1052, s. 6 5Section 6. 601.47 (3) of the statutes is amended to read:
AB1052,4,96 601.47 (3) Free distribution. The commissioner may furnish free copies of the
7publications prepared under subs. (1) and, (2), and (2m) to public officers and
8libraries in this state and elsewhere. The cost of free distribution shall be charged
9to the appropriation under s. 20.145 (1) (g).
AB1052, s. 7 10Section 7. 609.01 (4) of the statutes is renumbered 600.03 (37m) and amended
11to read:
AB1052,4,1912 600.03 (37m) "Preferred provider plan" means a health care plan, as defined
13in s. 628.36 (2) (a) 1., that is
offered by an organization established under ch. 185, 611,
14613, or 614 or issued a certificate of authority under ch. 618 and that makes available
15to its enrollees, without referral and for consideration other than predetermined
16periodic fixed payments, coverage of either comprehensive health care services or a
17limited range of health care services, regardless of whether the health care services
18are performed by participating, as defined in s. 609.01 (3m), or nonparticipating
19providers, as defined in s. 609.01 (5m).
AB1052, s. 8 20Section 8. 609.01 (4g) of the statutes is created to read:
AB1052,5,221 609.01 (4g) Notwithstanding s. 600.03 (37m), "preferred provider plan" means
22a health benefit plan offered by an organization established under ch. 185, 611, 613,
23or 614 or issued a certificate of authority under ch. 618 that makes available to its
24enrollees, without referral and for consideration other than predetermined periodic
25fixed payments, coverage of either comprehensive health care services or a limited

1range of health care services, regardless of whether the health care services are
2performed by participating or nonparticipating providers.
AB1052, s. 9 3Section 9. 609.20 (3) of the statutes is created to read:
AB1052,5,64 609.20 (3) (a) Except as provided otherwise in this chapter, the commissioner
5may not promulgate a rule or impose any requirement that regulates a contract
6between a preferred provider plan and its participating providers.
AB1052,5,97 (b) The commissioner may not promulgate a rule that establishes limits on, or
8that requires certain amounts or levels for, copayments, deductibles, or penalties
9imposed by preferred provider plans.
AB1052, s. 10 10Section 10. 609.20 (4) of the statutes is created to read:
AB1052,5,1311 609.20 (4) The commissioner may not promulgate a rule that requires a defined
12network plan to provide notice about nonparticipating provider limitations in
13addition to the notice required under s. 609.23 (1).
AB1052, s. 11 14Section 11. 609.22 (1m) of the statutes is created to read:
AB1052,5,1715 609.22 (1m) Access standards for preferred provider plans. (a) A preferred
16provider plan meets all of the requirements in sub. (1) if the preferred provider plan
17does all of the following:
AB1052,5,1918 1. Ensures that each enrollee has access, consistent with normal practices and
19standards in the geographic area, to at least one primary care provider.
AB1052,5,2220 2. Ensures that, for the provision of obstetric and gynecologic services, each
21female enrollee has access, consistent with normal practices and standards in the
22geographic area, to at least one primary care provider who provides those services.
AB1052,6,223 (b) Except as provided in this section and in s. 609.20, the commissioner may
24not promulgate a rule that imposes any additional requirements for preferred

1provider plans relative to access to primary care providers or obstetric and
2gynecologic services.
AB1052, s. 12 3Section 12. 609.22 (9) of the statutes is created to read:
AB1052,6,74 609.22 (9) Prohibition on use of utilization management. An insurer offering
5a preferred provider plan may not use utilization management techniques, including
6prior authorization requirements or similar methods, to deny access to
7nonparticipating providers.
AB1052, s. 13 8Section 13. 609.23 of the statutes is created to read:
AB1052,6,11 9609.23 Required notices. (1) Defined network plans. A defined network
10plan shall include in its marketing materials, in substantially similar language, the
11following notice:
AB1052,6,12 12IMPORTANT NOTICE
AB1052,6,14 13YOUR BENEFITS MAY BE REDUCED WHEN
14 NONPARTICIPATING PROVIDERS ARE USED
AB1052,6,20 15Please be aware that your benefits when you use participating
16providers may be different from the benefits when you use
17nonparticipating providers. Your plan may actually reduce your benefits
18when you use nonparticipating providers. To find out about your benefits,
19please read the benefit information found in these materials and in your
20plan documents, or you may call [insert phone number of insurer].
AB1052,6,22 21(2) Preferred provider plans. A preferred provider plan shall include in its
22provider directory, in substantially similar language, the following notice:
AB1052,6,23 23IMPORTANT NOTICE
AB1052,7,10 24You are strongly encouraged to contact us to verify the status of the
25providers involved in your care including, for example, the

1anesthesiologist, radiologist, pathologist, facility, clinic, or laboratory,
2when scheduling appointments or elective procedures to determine
3whether each provider is a participating or nonparticipating provider.
4Such information may assist you in your selection of providers and will
5likely affect the level of copayment, deductible, and coinsurance applicable
6to the care you receive. The information contained in this directory may
7change during your plan year. Please contact [insert phone number of
8insurer] to learn more about the participating providers in your network
9and the implications, including financial, if you decide to receive your care
10from nonparticipating providers.
AB1052, s. 14 11Section 14. 609.35 of the statutes is renumbered 609.35 (2).
AB1052, s. 15 12Section 15. 609.35 (1) of the statutes is created to read:
AB1052,7,1513 609.35 (1) In this section, a preferred provider plan covers the same service
14when performed by a nonparticipating provider that it covers when performed by a
15participating provider, if any of the following applies:
AB1052,7,1716 (a) The coinsurance differential between a participating and a
17nonparticipating provider paid by an enrollee for the service is 40 percent or less.
AB1052,7,1918 (b) Coinsurance paid by an enrollee for the service when performed by a
19nonparticipating provider is 50 percent or less.
AB1052, s. 16 20Section 16. 609.82 of the statutes is renumbered 609.82 (1).
AB1052, s. 17 21Section 17. 609.82 (2) of the statutes is created to read:
AB1052,8,222 609.82 (2) (a) Except as provided in pars. (b) and (c), if a preferred provider plan
23provides coverage of emergency medical services, the preferred provider plan shall
24cover emergency medical services provided to an enrollee during the treatment of an
25emergency medical condition, as defined in s. 632.85 (1) (a), by a nonparticipating

1provider as though the services were provided by a participating provider, if any of
2the following applies:
AB1052,8,43 1. The enrollee could not reasonably reach a participating provider for
4treatment of the emergency medical condition.
AB1052,8,65 2. As a result of the emergency, the enrollee was admitted to a nonparticipating
6provider for inpatient care.
AB1052,8,117 (b) The coverage under par. (a) may be subject to any restrictions that govern
8payment to a participating provider for emergency medical services. The preferred
9provider plan shall pay the nonparticipating provider at the rate at which it pays a
10nonparticipating provider, after applying any copayments, deductibles, or other
11cost-sharing requirements that apply to a participating provider.
AB1052,8,1412 (c) A preferred provider plan is required to provide the coverage under par. (a)
13only with respect to services that are needed to stabilize, as defined in section 1867
14of the federal Social Security Act, the enrollee's emergency medical condition.
AB1052, s. 18 15Section 18. 611.67 (1) (d) of the statutes is repealed.
AB1052, s. 19 16Section 19. 628.36 (2m) (a) 3. of the statutes is repealed.
AB1052, s. 20 17Section 20. 632.745 (15) of the statutes is amended to read:
AB1052,8,2418 632.745 (15) "Insurer" means an insurer that is authorized to do business in
19this state, in one or more lines of insurance that includes health insurance, and that
20offers health benefit plans covering individuals in this state or eligible employees of
21one or more employers in this state. The term includes a health maintenance
22organization, a preferred provider plan, as defined in s. 609.01 (4), an insurer
23operating as a cooperative association organized under ss. 185.981 to 185.985 and
24a limited service health organization, as defined in s. 609.01 (3).
AB1052, s. 21 25Section 21. 632.84 (3) of the statutes is amended to read:
AB1052,9,3
1632.84 (3) Exceptions. This section does not apply to a health maintenance
2organization, as defined in s. 609.01 (2), limited service health organization, as
3defined in s. 609.01 (3),
or preferred provider plan, as defined in s. 609.01.
AB1052, s. 22 4Section 22. 632.86 (1) (a) of the statutes is amended to read:
AB1052,9,105 632.86 (1) (a) "Disability insurance policy" has the meaning given in s. 632.895
6(1) (a), except that the term does not include coverage under a health maintenance
7organization, as defined in s. 609.01 (2), a limited service health organization, as
8defined in s. 609.01 (3), a preferred provider plan, as defined in s. 609.01 (4), or a
9sickness care plan operated by a cooperative association organized under ss. 185.981
10to 185.985.
AB1052, s. 23 11Section 23. 632.895 (14) (d) 3. of the statutes is amended to read:
AB1052,9,1412 632.895 (14) (d) 3. A health care plan offered by a limited service health
13organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined
14in s. 609.01 (4),
that is not a defined network plan, as defined in s. 609.01 (1b).
AB1052, s. 24 15Section 24. 635.02 (8) of the statutes is amended to read:
AB1052,9,2416 635.02 (8) "Small employer insurer" means an insurer that is authorized to do
17business in this state, in one or more lines of insurance that includes health
18insurance, and that offers group health benefit plans covering eligible employees of
19one or more small employers in this state, or that sells 3 or more individual health
20benefit plans to a small employer, covering eligible employees of the small employer.
21The term includes a health maintenance organization, as defined in s. 609.01 (2), a
22preferred provider plan, as defined in s. 609.01 (4), and an insurer operating as a
23cooperative association organized under ss. 185.981 to 185.985, but does not include
24a limited service health organization, as defined in s. 609.01 (3).
AB1052, s. 25 25Section 25. Initial applicability.
AB1052,10,3
1(1) Coverage of same services and emergency medical services. The
2renumbering of sections 609.35 and 609.82 of the statutes and the creation of
3sections 609.35 (1) and 609.82 (2) of the statutes first apply to all of the following:
AB1052,10,54 (a) Except as provided in paragraph (b), policies, plans, or contracts that are
5issued or renewed on the effective date of this paragraph.
AB1052,10,106 (b) Policies, plans, or contracts covering employees who are affected by a
7collective bargaining agreement containing provisions inconsistent with the
8renumbering of sections 609.35 and 609.82 of the statutes and the creation of
9sections 609.35 (1) and 609.82 (2) of the statutes that are issued or renewed on the
10earlier of the following:
AB1052,10,11 111. The day on which the collective bargaining agreement expires.
AB1052,10,13 122. The day on which the collective bargaining agreement is extended, modified,
13or renewed.
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