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2007 - 2008 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2007 SENATE BILL 337
January 25, 2008 - Offered by Senator Sullivan.
SB337-SSA1,1,4 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 health care consumers with certain charge or
payment rate information, upon request by and at no cost to the consumers; 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 consumer's request, provide the consumer with the
median billed charges (as defined in the substitute amendment), assuming no
complications, for inpatient or outpatient health care services, diagnostic tests, or
procedures provided by the health care provider that the consumer specifies. In
addition, upon request, the health care provider must immediately, on site, provide
the consumer with all of the following information, as a single document:
1. 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.
2. If the health care provider is certified as a provider of Medical Assistance
(MA), the MA payment rates for the provider's 25 most frequently performed health
care services, diagnostic tests, or procedures.
3. If the health care provider is certified as a provider of Medicare, the Medicare
payment rates for the provider's 25 most frequently performed health care services,
diagnostic tests, or procedures.
4. The average allowable payment from private, third-party payers for the
provider's 25 most frequently performed health care services, diagnostic tests, or
procedures.
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 median reimbursement that the insurer or self-insured health plan
would expect to pay for a specified health care service in the geographic region in
which the service will be provided. In addition, the insurer or self-insured health
plan must provide to an insured or enrollee a good faith estimate of the insured's or
enrollee's total out-of-pocket cost for the specified service. 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 any of 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, and the provider's estimate of the
charges. However, the insurer or self-insured health plan may not require the
insured or enrollee to provide the Current Procedural Terminology code or Current
Dental Terminology code for the service as a condition of providing the information.
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 health care consumers of the consumers' right to
request charge or payment rate 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:
SB337-SSA1, s. 1
1Section 1. 40.51 (8) of the statutes, as affected by 2007 Wisconsin Act 36, is
2amended to read:
SB337-SSA1,3,63 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.
SB337-SSA1, s. 2 7Section 2. 40.51 (8m) of the statutes, as affected by 2007 Wisconsin Act 36, is
8amended to read:
SB337-SSA1,3,119 40.51 (8m) Every health care coverage plan offered by the group insurance
10board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
11632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to (15).
SB337-SSA1, s. 3 12Section 3. 66.0137 (4) of the statutes, as affected by 2007 Wisconsin Act 36,
13is amended to read:
SB337-SSA1,3,1914 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
15a village provides health care benefits under its home rule power, or if a town
16provides health care benefits, to its officers and employees on a self-insured basis,
17the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
18632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87
19(4) and, (5), and (6), 632.895 (9) to (15), 632.896, and 767.25 (4m) (d) 767.513 (4).
SB337-SSA1, s. 4 20Section 4. 120.13 (2) (g) of the statutes, as affected by 2007 Wisconsin Act 36,
21is amended to read:
SB337-SSA1,3,2522 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
2349.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
24632.798, 632.85, 632.853, 632.855, 632.87 (4) and, (5), and (6), 632.895 (9) to (15),
25632.896, and 767.25 (4m) (d) 767.513 (4).
SB337-SSA1, s. 5
1Section 5. 146.903 of the statutes is created to read:
SB337-SSA1,4,3 2146.903 Disclosures required of health care providers. (1) In this
3section:
SB337-SSA1,4,64 (a) "All-patient refined diagnosis-related groups" means a system of
5classifying inpatient hospital discharges that applies to patients of any age and
6distinguishes among 4 levels of severity of illness within each classification.
SB337-SSA1,4,77 (b) "Ambulatory surgery center" has the meaning given in 42 CFR 416.2.
SB337-SSA1,4,108 (c) "Clinic" means a place, other than a residence, that is used primarily for the
9provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and
10treatment.
SB337-SSA1,4,1211 (d) "Diagnosis-related groups" means a classification of inpatient hospital
12discharges specified under 42 CFR 412.60.
SB337-SSA1,4,1413 (e) "Health care provider" has the meaning given in s. 146.81 (1) and includes
14a clinic and an ambulatory surgery center.
SB337-SSA1,4,2115 (f) "Median billed charge" means the amount that a health care provider
16charged for a health care service, diagnostic test, or procedure, before any discount
17or contractual rate applicable to certain patients or payers was applied, during the
18first 2 calendar quarters of the most recently completed calendar year, as calculated
19by arranging the charges in that reporting period from highest to lowest and
20selecting the middle charge in the sequence or, for an even number of charges,
21selecting the 2 middle charges in the sequence and calculating the average of the 2.
SB337-SSA1,4,2322 (g) "Medical Assistance" means health care benefits provided under subch. IV
23of ch. 49.
SB337-SSA1,4,2524 (h) "Medicare" means coverage under part A or part B of Title XVIII of the
25federal Social Security Act, 42 USC 1395 to 1395dd.
SB337-SSA1,5,3
1(2) Except as provided in sub. (5), a health care provider or the health care
2provider's designee shall, upon request by and at no cost to a health care consumer,
3disclose to the consumer all of the following, under the following circumstances:
SB337-SSA1,5,74 (a) Within a reasonable period of time after the request, the median billed
5charge, assuming no medical complications, for an inpatient or outpatient health
6care service, diagnostic test, or procedure that is specified by the consumer and that
7is provided by the health care provider.
SB337-SSA1,5,98 (b) Immediately upon request, on the site of the health care provider, as a single
9document, all of the following:
SB337-SSA1,5,1410 1. The median billed charge, assuming no medical complications, for each of 25
11health care services, diagnostic tests, or procedures, relevant to the treatment of
12particular presenting conditions, as specified annually by the department based on
13claims data under Medical Assistance from the most recently-completed fiscal year.
14The information under this subdivision shall be classified as follows:
SB337-SSA1,5,1615 a. If provided concerning inpatient services by a hospital, by diagnosis-related
16groups or all-patient refined diagnosis-related groups.
SB337-SSA1,5,1817 b. If provided concerning outpatient services by a hospital, or if provided by an
18ambulatory surgery center, by surgical procedure code.
SB337-SSA1,5,2519 c. If provided by a physician, under a classification of physician specialities that
20is specified by the department, by presenting conditions, including the total charges
21for codes under the Current Procedural Terminology of the American Medical
22Association that are most frequently performed as a result of the presenting
23conditions. "Presenting conditions" under this subd. 1. c. shall be defined by the
24department after consulting with the Wisconsin Collaborative for Healthcare
25Quality.
SB337-SSA1,6,8
1d. If provided by a health care provider other than a hospital or physician, by
2a grouping form similar to that under subd. 1. a., b., or c. Notwithstanding the
3requirement under subd. 1. (intro.) that 25 health care services, diagnostic tests, or
4procedures be disclosed, if the health care provider under this subd. 1. d. performs
5fewer than 25 health care services, diagnostic tests, or procedures on a regular basis,
6the health care provider shall indicate that fact and disclose those health care
7services, diagnostic tests, or procedures that the health care provider performs on a
8regular basis.
SB337-SSA1,6,119 2. If the health care provider is certified as a provider of Medical Assistance,
10the Medical Assistance payment rates for the provider for the health care services,
11diagnostic tests, or procedures specified in subd. 1.
SB337-SSA1,6,1412 3. If the health care provider is certified as a provider of Medicare, the Medicare
13payment rates for the provider for the health care services, diagnostic tests, or
14procedures specified in subd. 1.
SB337-SSA1,6,1615 4. The average allowable payment from private, 3rd-party payers for the
16health care services, diagnostic tests, or procedures specified in subd. 1.
SB337-SSA1,6,19 17(3) Information on charges or payment rates that is provided to a health care
18consumer under sub. (2) shall be updated annually by the health care provider and
19may not be construed as a legally binding estimate of the cost to the consumer.
SB337-SSA1,7,2 20(4) Except as provided in sub. (5), a health care provider shall prominently
21display, in the area of the health care provider's practice or facility that is most
22commonly frequented by health care consumers, a statement informing the
23consumers that they have the right to request charge or payment rate information
24for health care services, diagnostic tests, or procedures from the health care provider

1or, if the requirements under s. 632.798 (2) (e) are met, all of the following from their
2insurers or self-insured health plans:
SB337-SSA1,7,53 (a) A good faith estimate of the median reimbursement that the insurer or
4self-insured health plan would expect to pay for a specified health care service in the
5geographic region in which the health care service will be provided.
SB337-SSA1,7,86 (b) A good faith estimate of the insured's total out-of-pocket cost according to
7the insured's benefit terms for the specified health care service in the geographic
8region in which the health care service will be provided.
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