LRBs0265/1
DAK&PJK:cjs:nwn
2007 - 2008 LEGISLATURE
ASSEMBLY SUBSTITUTE AMENDMENT 1,
TO 2007 ASSEMBLY BILL 729
February 11, 2008 - Offered by Representative Wieckert.
AB729-ASA1,1,4
1An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.981 (4t)
2and 185.983 (1) (intro.); and
to create 146.903, 609.71 and 632.798 of the
3statutes;
relating to: disclosure of information by health care providers and
4insurers and providing a penalty.
Analysis by the Legislative Reference Bureau
This substitute amendment requires health care providers, as defined in the
substitute amendment, to provide patients of the health care providers with certain
charge information, upon request by and at no cost to the patients; the information
must be updated annually and may not be construed as a legally binding estimate.
Under the substitute amendment, a health care provider must, within a reasonable
period of time after a patient's request, provide the patient with the median billed
charges (as defined in the substitute amendment), assuming no complications, and
the appropriate Current Procedural Terminology code of the American Medical
Association (CPT code), for inpatient or outpatient health care services, diagnostic
tests, or procedures provided by the health care provider that the patient specifies.
In addition, upon request, the health care provider must immediately, on site,
provide the patient with the median billed charge, assuming no medical
complications, for each of 25 health care services, diagnostic tests, or procedures,
relevant to the treatment of particular presenting conditions, as specified annually
by the Department of Health and Family Services (DHFS). This information must
be classified by diagnosis-related groups or all-patient refined diagnosis-related
groups, if provided by a hospital for inpatient services; by surgical procedure code,
if provided by a hospital for outpatient services or if provided by an ambulatory
surgery center; by presenting conditions, if provided by a physician; and by a
grouping form similar to that for a hospital or a physician, if provided by a health care
provider that is not a hospital or a physician.
Under the substitute amendment, a violation of these requirements is subject
to an administrative forfeiture of up to $500.
Under the substitute amendment, a self-insured health plan of the state or a
county, city, village, town, or school district, or an insurer that provides coverage
under a health insurance policy, including defined network plans and sickness care
plans operated by cooperative associations, must provide to an insured under the
health insurance policy or an enrollee under the self-insured health plan a good faith
estimate of the insured's or enrollee's total out-of-pocket cost for a specified health
care service in the geographic region in which the service will be provided. The
information must be provided only if the insured or enrollee requests it, and it must
be provided at no charge to the insured or enrollee. Before providing the information,
the insurer or self-insured health plan may require the insured or enrollee to provide
the name of the provider providing the service, the facility at which the service will
be provided, the date the service will be provided, the provider's estimate of the
charges, and the CPT code or Current Dental Terminology code for the service. In
addition, the substitute amendment provides that any good faith estimate provided
is not a legally binding estimate.
The substitute amendment also requires health care providers to display
prominently statements informing patients of the health care providers of the
patients' right to request charge information for health care services, diagnostic
tests, or procedures from the health care providers or from their insurers.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB729-ASA1,2,63
40.51
(8) Every health care coverage plan offered by the state under sub. (6)
4shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
5and (10), 632.747, 632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
6632.87 (3) to
(5) (6), 632.895 (5m) and (8) to (15), and 632.896.
AB729-ASA1,3,53
40.51
(8m) Every health care coverage plan offered by the group insurance
4board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
5632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to (15).
AB729-ASA1,3,138
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
9a village provides health care benefits under its home rule power, or if a town
10provides health care benefits, to its officers and employees on a self-insured basis,
11the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
12632.746 (10) (a) 2. and (b) 2., 632.747 (3),
632.798, 632.85, 632.853, 632.855, 632.87
13(4)
and, (5),
and (6), 632.895 (9) to (15), 632.896, and
767.25 (4m) (d)
767.513 (4).
AB729-ASA1,3,1916
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
1749.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
18632.798, 632.85, 632.853, 632.855, 632.87 (4)
and, (5),
and (6), 632.895 (9) to (15),
19632.896, and
767.25 (4m) (d) 767.513 (4).
AB729-ASA1,3,22
21146.903 Disclosures required of health care providers. (1) In this
22section:
AB729-ASA1,3,2523
(a) "All-patient refined diagnosis-related groups" means a system of
24classifying inpatient hospital discharges that applies to patients of any age and
25distinguishes among 4 levels of severity of illness within each classification.
AB729-ASA1,4,1
1(b) "Ambulatory surgery center" has the meaning given in
42 CFR 416.2.
AB729-ASA1,4,42
(c) "Clinic" means a place, other than a residence, that is used primarily for the
3provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and
4treatment.
AB729-ASA1,4,65
(d) "Diagnosis-related groups" means a classification of inpatient hospital
6discharges specified under
42 CFR 412.60.
AB729-ASA1,4,87
(e) "Health care provider" has the meaning given in s. 146.81 (1) and includes
8a clinic and an ambulatory surgery center.
AB729-ASA1,4,159
(f) "Median billed charge" means the amount that a health care provider
10charged for a health care service, diagnostic test, or procedure, before any discount
11or contractual rate applicable to certain patients or payers was applied, during the
12first 2 calendar quarters of the most recently completed calendar year, as calculated
13by arranging the charges in that reporting period from highest to lowest and
14selecting the middle charge in the sequence or, for an even number of charges,
15selecting the 2 middle charges in the sequence and calculating the average of the 2.
AB729-ASA1,4,1716
(g) "Medical Assistance" means health care benefits provided under subch. IV
17of ch. 49.
AB729-ASA1,4,21
18(2) Except as provided in sub. (5), a health care provider or the health care
19provider's designee shall, upon request by and at no cost to an individual patient of
20the health care provider, for the patient's own use, disclose to the patient all of the
21following, under the following circumstances:
AB729-ASA1,4,2422
(a) Within a reasonable period of time after the request, for an inpatient or
23outpatient health care service, diagnostic test, or procedure that is specified by the
24patient and that is provided by the health care provider, all of the following:
AB729-ASA1,4,2525
1. The median billed charge, assuming no medical complications.
AB729-ASA1,5,2
12. The appropriate code under the Current Procedural Terminology of the
2American Medical Association.
AB729-ASA1,5,83
(b) Immediately upon request, on the site of the health care provider, the
4median billed charge, assuming no medical complications, for each of 25 health care
5services, diagnostic tests, or procedures, relevant to the treatment of particular
6presenting conditions, as specified annually by the department based on claims data
7under Medical Assistance from the most recently-completed fiscal year. The
8information under this paragraph shall be classified as follows:
AB729-ASA1,5,109
1. If provided concerning inpatient services by a hospital, by diagnosis-related
10groups or all-patient refined diagnosis-related groups.
AB729-ASA1,5,1211
2. If provided concerning outpatient services by a hospital, or if provided by an
12ambulatory surgery center, by surgical procedure code.
AB729-ASA1,5,1913
3. If provided by a physician, under a classification of physician specialities
14that is specified by the department, by presenting conditions, including the total
15charges for codes under the Current Procedural Terminology of the American
16Medical Association that are most frequently performed as a result of the presenting
17conditions. "Presenting conditions" under this subdivision shall be defined by the
18department after consulting with the Wisconsin Collaborative for Healthcare
19Quality.
AB729-ASA1,6,220
4. If provided by a health care provider other than a hospital or physician, by
21a grouping form similar to that under subd. 1., 2., or 3. Notwithstanding the
22requirement under par. (b) (intro.) that 25 health care services, diagnostic tests, or
23procedures be disclosed, if the health care provider under this subdivision performs
24fewer than 25 health care services, diagnostic tests, or procedures on a regular basis,
25the health care provider shall indicate that fact and disclose those health care
1services, diagnostic tests, or procedures that the health care provider performs on a
2regular basis.
AB729-ASA1,6,5
3(3) Information on charges that is provided to a patient under sub. (2) shall be
4updated annually by the health care provider and may not be construed as a legally
5binding estimate of the cost to the patient.
AB729-ASA1,6,14
6(4) Except as provided in sub. (5), a health care provider shall prominently
7display, in the area of the health care provider's practice or facility that is most
8commonly frequented by patients, a statement informing the patients that they have
9the right to request charge information for health care services, diagnostic tests, or
10procedures from the health care provider or, if the requirements under s. 632.798 (2)
11(d) are met, a good faith estimate, from their insurers or self-insured health plans,
12of the insured's total out-of-pocket cost according to the insured's benefit terms for
13the specified health care service in the geographic region in which the health care
14service will be provided.
AB729-ASA1,6,15
15(5) This section does not apply to any of the following:
AB729-ASA1,6,1716
(a) A health care provider that practices individually and not in association
17with another health care provider.
AB729-ASA1,6,1918
(b) Health care providers that are an association of 3 or fewer individual health
19care providers.
AB729-ASA1,6,21
20(6) (a) Whoever violates this section may be required to forfeit not more than
21$500 for each violation.
AB729-ASA1,7,222
(b) The department may directly assess forfeitures provided for under par. (a).
23If the department determines that a forfeiture should be assessed for a particular
24violation, the department shall send a notice of assessment to the alleged violator.
25The notice shall specify the amount of the forfeiture assessed, the violation, and the
1statute or rule alleged to have been violated, and shall inform the alleged violator of
2the right to a hearing under par. (c).
AB729-ASA1,7,143
(c) An alleged violator may contest an assessment of a forfeiture by sending,
4within 10 days after receipt of notice under par. (b), a written request for a hearing
5under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1).
6The administrator of the division may designate a hearing examiner to preside over
7the case and recommend a decision to the administrator under s. 227.46. The
8decision of the administrator of the division shall be the final administrative
9decision. The division shall commence the hearing within 30 days after receipt of the
10request for a hearing and shall issue a final decision within 15 days after the close
11of the hearing. Proceedings before the division are governed by ch. 227. In any
12petition for judicial review of a decision by the division, the party, other than the
13petitioner, who was in the proceeding before the division shall be the named
14respondent.
AB729-ASA1,7,2015
(d) All forfeitures shall be paid to the department within 10 days after receipt
16of notice of assessment or, if the forfeiture is contested under par. (c), within 10 days
17after receipt of the final decision after exhaustion of administrative review, unless
18the final decision is appealed and the order is stayed by court order. The department
19shall remit all forfeitures paid to the secretary of administration for deposit in the
20school fund.
AB729-ASA1,7,2421
(e) The attorney general may bring an action in the name of the state to collect
22any forfeiture imposed under this subsection if the forfeiture has not been paid
23following the exhaustion of all administrative and judicial reviews. The only issue
24to be contested in any such action is whether the forfeiture has been paid.
AB729-ASA1,8,63
185.981
(4t) A sickness care plan operated by a cooperative association is
4subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749,
632.798, 5632.85, 632.853, 632.855, 632.87 (2m), (3), (4),
and (5),
and (6), 632.895 (10) to (15),
6and 632.897 (10) and chs. 149 and 155.
AB729-ASA1,8,159
185.983
(1) (intro.) Every such voluntary nonprofit sickness care plan shall be
10exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
11601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
12631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795,
632.798, 632.85,
13632.853, 632.855, 632.87 (2m), (3), (4),
and (5),
and (6), 632.895 (5) and (9) to (15),
14632.896, and 632.897 (10) and chs. 609, 630, 635, 645
, and 646, but the sponsoring
15association shall:
AB729-ASA1,8,19
17609.71 Disclosure of out-of-pocket costs. Limited service health
18organizations, preferred provider plans, and defined network plans are subject to s.
19632.798.