LRB-3424/2
DAK&PJK:cjs:jf
2007 - 2008 LEGISLATURE
January 24, 2008 - Introduced by Representatives Wieckert, Moulton,
Hraychuck, M. Williams, Molepske, Van Roy, Musser, Shilling, Murtha,
Montgomery, F. Lasee, Gunderson, Kestell, Fields, Jeskewitz, Hixson,
Petersen, Wood, Davis, Bies, Mursau, Vos, Petrowski, Hines, Strachota,
Albers, Grigsby, Sheridan, Seidel, A. Williams, Wasserman, Krusick and
Kreuser, cosponsored by Senators Sullivan, Kreitlow, Cowles, Lehman,
Roessler, Harsdorf, Darling, Robson, Taylor and Grothman. Referred to
Committee on Small Business.
AB729,1,4
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 bill requires health care providers, as defined in the bill, 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 bill, 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 bill), 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 bill, a violation of these requirements is subject to an administrative
forfeiture of up to $500.
Under the bill, 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 bill provides that any good faith estimate provided is not a legally
binding estimate.
The bill 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.
For further information see the state and local fiscal estimate, which will be
printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB729,3,63
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.
AB729,3,119
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).
AB729,3,1914
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).
AB729,3,2522
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).
AB729, s. 5
1Section
5. 146.903 of the statutes is created to read:
AB729,4,3
2146.903 Disclosures required of health care providers. (1) In this
3section:
AB729,4,64
(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.
AB729,4,77
(b) "Ambulatory surgery center" has the meaning given in
42 CFR 416.2.
AB729,4,108
(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.
AB729,4,1211
(d) "Diagnosis-related groups" means a classification of inpatient hospital
12discharges specified under
42 CFR 412.60.
AB729,4,1413
(e) "Health care provider" has the meaning given in s. 146.81 (1) and includes
14a clinic and an ambulatory surgery center.
AB729,4,2115
(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.
AB729,4,2322
(g) "Medical Assistance" means health care benefits provided under subch. IV
23of ch. 49.
AB729,4,2524
(h) "Medicare" means coverage under part A or part B of Title XVIII of the
25federal Social Security Act,
42 USC 1395 to
1395dd.
AB729,5,3
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:
AB729,5,74
(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.
AB729,5,98
(b) Immediately upon request, on the site of the health care provider, as a single
9document, all of the following:
AB729,5,1410
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:
AB729,5,1615
a. If provided concerning inpatient services by a hospital, by diagnosis-related
16groups or all-patient refined diagnosis-related groups.
AB729,5,1817
b. If provided concerning outpatient services by a hospital, or if provided by an
18ambulatory surgery center, by surgical procedure code.
AB729,5,2519
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.
AB729,6,8
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.
AB729,6,119
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.
AB729,6,1412
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.
AB729,6,1615
4. The average allowable payment from private, 3rd-party payers for the
16health care services, diagnostic tests, or procedures specified in subd. 1.
AB729,6,19
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.
AB729,7,2
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:
AB729,7,53
(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.
AB729,7,86
(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.
AB729,7,9
9(5) This section does not apply to any of the following:
AB729,7,1110
(a) A health care provider that practices individually and not in association
11with another health care provider.
AB729,7,1312
(b) Health care providers that are an association of 3 or fewer individual health
13care providers.
AB729,7,15
14(6) (a) Whoever violates this section may be required to forfeit not more than
15$500 for each violation.
AB729,7,2116
(b) The department may directly assess forfeitures provided for under par. (a).
17If the department determines that a forfeiture should be assessed for a particular
18violation, the department shall send a notice of assessment to the alleged violator.
19The notice shall specify the amount of the forfeiture assessed, the violation, and the
20statute or rule alleged to have been violated, and shall inform the alleged violator of
21the right to a hearing under par. (c).
AB729,8,822
(c) An alleged violator may contest an assessment of a forfeiture by sending,
23within 10 days after receipt of notice under par. (b), a written request for a hearing
24under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1).
25The administrator of the division may designate a hearing examiner to preside over
1the case and recommend a decision to the administrator under s. 227.46. The
2decision of the administrator of the division shall be the final administrative
3decision. The division shall commence the hearing within 30 days after receipt of the
4request for a hearing and shall issue a final decision within 15 days after the close
5of the hearing. Proceedings before the division are governed by ch. 227. In any
6petition for judicial review of a decision by the division, the party, other than the
7petitioner, who was in the proceeding before the division shall be the named
8respondent.
AB729,8,149
(d) All forfeitures shall be paid to the department within 10 days after receipt
10of notice of assessment or, if the forfeiture is contested under par. (c), within 10 days
11after receipt of the final decision after exhaustion of administrative review, unless
12the final decision is appealed and the order is stayed by court order. The department
13shall remit all forfeitures paid to the secretary of administration for deposit in the
14school fund.
AB729,8,1815
(e) The attorney general may bring an action in the name of the state to collect
16any forfeiture imposed under this subsection if the forfeiture has not been paid
17following the exhaustion of all administrative and judicial reviews. The only issue
18to be contested in any such action is whether the forfeiture has been paid.
AB729,8,2421
185.981
(4t) A sickness care plan operated by a cooperative association is
22subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749,
632.798, 23632.85, 632.853, 632.855, 632.87 (2m), (3), (4),
and (5),
and (6), 632.895 (10) to (15),
24and 632.897 (10) and chs. 149 and 155.
AB729,9,93
185.983
(1) (intro.) Every such voluntary nonprofit sickness care plan shall be
4exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
5601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
6631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795,
632.798, 632.85,
7632.853, 632.855, 632.87 (2m), (3), (4),
and (5),
and (6), 632.895 (5) and (9) to (15),
8632.896, and 632.897 (10) and chs. 609, 630, 635, 645
, and 646, but the sponsoring
9association shall:
AB729, s. 8
10Section
8. 609.71 of the statutes is created to read:
AB729,9,12
11609.71 Disclosure of payments. Limited service health organizations,
12preferred provider plans, and defined network plans are subject to s. 632.798.
AB729, s. 9
13Section
9. 632.798 of the statutes is created to read:
AB729,9,14
14632.798 Disclosure of payments. (1) Definitions. In this section:
AB729,9,1515
(a) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).
AB729,9,1716
(b) "Insured" includes an enrollee under a self-insured health plan and a
17representative or designee of an insured or enrollee.
AB729,9,1918
(c) "Self-insured health plan" means a self-insured health plan of the state or
19a county, city, village, town, or school district.
AB729,9,25
20(2) Provide information. (a) A self-insured health plan or an insurer that
21provides coverage under a disability insurance policy shall, at the request of an
22insured, provide to the insured a good faith estimate of the median reimbursement
23that the insurer or self-insured health plan would expect to pay for a specified health
24care service in the geographic region in which the health care service will be
25provided.
AB729,10,5
1(b) If requested by the insured, the insurer or self-insured health plan under
2par. (a) shall also provide to the insured a good faith estimate, as of the date of the
3request, of the insured's total out-of-pocket cost according to the insured's benefit
4terms for the specified health care service in the geographic region in which the
5health care service will be provided.
AB729,10,76
(c) An estimate provided by an insurer or self-insured health plan under this
7section is not a legally binding estimate of the reimbursement or out-of-pocket cost.
AB729,10,98
(d) An insurer or self-insured health plan may not charge an insured for
9providing the information under this section.
AB729,10,1210
(e) 1. Before providing any of the information requested under par. (a) or (b),
11the insurer or self-insured health plan may require the insured to provide any of the
12following information:
AB729,10,1313
a. The name of the provider providing the service.