LRB-3210/1
DAK&PJK:cjs:pg
2007 - 2008 LEGISLATURE
November 21, 2007 - Introduced by Senators Sullivan, Kreitlow, Lehman, Cowles,
Roessler, Darling, Robson and Taylor, cosponsored by Representatives
Wieckert, Moulton, Musser, Albers, Grigsby, Sheridan, Seidel, A. Williams,
Shilling, Wood, Jeskewitz, Wasserman, F. Lasee, Krusick, Hraychuck and
Kreuser. Referred to Committee on Health, Human Services, Insurance, and
Job Creation.
SB337,1,4
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.
Analysis by the Legislative Reference Bureau
This bill requires health care providers, as defined and limited 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 the request,
provide the consumer with the usual and customary charges, 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 usual and customary charge, assuming no medical complications, for
each of the 50 health care services, diagnostic tests, or procedures, relevant to the
treatment of particular presenting conditions, that the health care provider most
frequently performs. This information must be classified in the form of
diagnosis-related groups, if provided by a hospital; in the form of presenting
conditions, if provided by a physician; and in 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, as specified on the Web site of the Department of
Health and Family Services, for the provider's 50 most frequently performed health
care services, diagnostic tests, or procedures.
3. The average allowable payment from private, third party payers for the
provider's 50 most frequently performed health care services, diagnostic tests, or
procedures.
4. The average of the charges and payment rates for each health care service,
diagnostic test, or procedure specified in 1. to 3., above.
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
reimbursement that the insurer or self-insured health plan would expect to pay a
specified provider for a specified health care service. 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 provided
by the specified provider. 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.
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:
SB337, s. 1
1Section
1. 40.51 (8) of the statutes is amended to read:
SB337,2,52
40.51
(8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
4and (10), 632.747, 632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
5632.87 (3) to (6), 632.895 (5m) and (8) to (14)
, and 632.896.
SB337, s. 2
6Section
2. 40.51 (8m) of the statutes is amended to read:
SB337,3,3
140.51
(8m) Every health care coverage plan offered by the group insurance
2board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
3632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855
, and 632.895 (11) to (14).
SB337, s. 3
4Section
3. 66.0137 (4) of the statutes is amended to read:
SB337,3,105
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
6a village provides health care benefits under its home rule power, or if a town
7provides health care benefits, to its officers and employees on a self-insured basis,
8the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
9632.746 (10) (a) 2. and (b) 2., 632.747 (3),
632.798, 632.85, 632.853, 632.855, 632.87
10(4), (5), and (6), 632.895 (9) to (14), 632.896
, and 767.513 (4).
SB337, s. 4
11Section
4. 120.13 (2) (g) of the statutes is amended to read:
SB337,3,1512
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
1349.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
14632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.895 (9) to (14),
15632.896
, and 767.513 (4).
SB337, s. 5
16Section
5. 146.903 of the statutes is created to read:
SB337,3,18
17146.903 Disclosures required of health care providers. (1) In this
18section:
SB337,3,1919
(a) "Ambulatory surgery center" has the meaning given in
42 CFR 416.2.
SB337,3,2220
(b) "Clinic" means a place, other than a residence, that is used primarily for the
21provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and
22treatment.
SB337,3,2423
(c) "Diagnosis-related groups" means a classification of inpatient hospital
24discharges specified under
42 CFR 412.60.
SB337,4,2
1(d) "Health care provider" has the meaning given in s. 146.81 (1) and includes
2a clinic and an ambulatory surgery center.
SB337,4,43
(e) "Medical Assistance" means health care benefits provided under subch. IV
4of ch. 49.
SB337,4,85
(f) "Usual and customary charge" means the amount that a health care provider
6usually and customarily charges for a health care service, diagnostic test, or
7procedure, before any discount or contractual rate applicable to certain patients or
8payers is applied.
SB337,4,11
9(2) Except as provided in sub. (5), a health care provider or the health care
10provider's designee shall, upon request by and at no cost to a health care consumer,
11disclose to the consumer all of the following, under the following circumstances:
SB337,4,1512
(a) Within a reasonable period of time after the request, the usual and
13customary charges, assuming no medical complications, for an inpatient or
14outpatient health care service, diagnostic test, or procedure that is specified by the
15consumer and that is provided by the health care provider.
SB337,4,1716
(b) Immediately upon request, on the site of the health care provider, as a single
17document, all of the following:
SB337,4,2218
1. The usual and customary charge, assuming no medical complications, for
19each of the 50 health care services, diagnostic tests, or procedures, relevant to the
20treatment of particular presenting conditions, that the health care provider most
21frequently performs. The information under this subdivision shall be classified as
22follows:
SB337,4,2423
a. If provided concerning inpatient or outpatient services by a hospital, in the
24form of diagnosis-related groups.
SB337,5,4
1b. If provided by a physician, in the form of presenting conditions, including the
2total charges for codes under the Current Procedural Terminology of the American
3Medical Association that are most frequently performed as a result of the presenting
4conditions.
SB337,5,125
c. If provided by a health care provider other than a hospital or physician, in
6a grouping form similar to that under subd. 1. a. or b. Notwithstanding the
7requirement under subd. 1. (intro.) that 50 health care services, diagnostic tests, or
8procedures be disclosed, if the health care provider under this subd. 1. c. performs
9fewer than 50 health care services, diagnostic tests, or procedures on a regular basis,
10the health care provider shall indicate that fact and disclose those health care
11services, diagnostic tests, or procedures that the health care provider performs on a
12regular basis.
SB337,5,1613
2. If the health care provider is certified as a provider of Medical Assistance,
14the Medical Assistance payment rates, as specified on the Web site of the
15department, for the provider for the health care services, diagnostic tests, or
16procedures specified in subd. 1.
SB337,5,1817
3. The average allowable payment from private, 3rd party payers for the health
18care services, diagnostic tests, or procedures specified in subd. 1.
SB337,5,2019
4. The average of the charges and payment rates specified in subd. 1., 2., and
203. for each health care service, diagnostic test, or procedure specified in subd. 1.
SB337,5,23
21(3) Information on charges or payment rates that is provided to a health care
22consumer under sub. (2) shall be updated annually by the health care provider and
23may not be construed as a legally binding estimate of the cost to the consumer.
SB337,6,5
24(4) Except as provided in sub. (5), a health care provider shall prominently
25display, in the area of the health care provider's practice or facility that is most
1commonly frequented by health care consumers, a statement informing the
2consumers that they have the right to request charge or payment rate information
3for health care services, diagnostic tests, or procedures from the health care provider
4or, under s. 632.798, all of the following from their insurers or self-insured health
5plans:
SB337,6,86
(a) A good faith estimate of the reimbursement that the insurer or self-insured
7health plan would expect to pay a specified provider for a specified health care
8service.
SB337,6,109
(b) A good faith estimate of the insured's total out-of-pocket cost for the
10specified health care service provided by the specified provider.
SB337,6,11
11(5) This section does not apply to any of the following:
SB337,6,1312
(a) A health care provider that practices individually and not in association
13with another health care provider.
SB337,6,1514
(b) Health care providers that are an association of 3 or fewer individual health
15care providers.
SB337, s. 6
16Section
6. 185.981 (4t) of the statutes is amended to read:
SB337,6,2017
185.981
(4t) A sickness care plan operated by a cooperative association is
18subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749,
632.798, 19632.85, 632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.895 (10) to (14)
, and
20632.897 (10) and chs. 149 and 155.
SB337, s. 7
21Section
7. 185.983 (1) (intro.) of the statutes is amended to read:
SB337,7,322
185.983
(1) (intro.) Every such voluntary nonprofit sickness care plan shall be
23exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
24601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
25631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795,
632.798, 632.85,
1632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.895 (5) and (9) to (14), 632.896
, 2and 632.897 (10) and chs. 609, 630, 635, 645
, and 646, but the sponsoring association
3shall:
SB337, s. 8
4Section
8. 609.71 of the statutes is created to read:
SB337,7,6
5609.71 Disclosure of payments. Limited service health organizations,
6preferred provider plans, and defined network plans are subject to s. 632.798.
SB337, s. 9
7Section
9. 632.798 of the statutes is created to read:
SB337,7,8
8632.798 Disclosure of payments. (1) Definitions. In this section:
SB337,7,99
(a) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).
SB337,7,1110
(b) "Insured" includes an enrollee under a self-insured health plan and a
11representative or designee of an insured or enrollee.
SB337,7,1312
(c) "Self-insured health plan" means a self-insured health plan of the state or
13a county, city, village, town, or school district.
SB337,7,18
14(2) Provide information. (a) A self-insured health plan or an insurer that
15provides coverage under a disability insurance policy shall, at the request of an
16insured, provide to the insured a good faith estimate of the reimbursement that the
17insurer or self-insured health plan would expect to pay a specified provider for a
18specified health care service.
SB337,7,2219
(b) If requested by the insured, the insurer or self-insured health plan under
20par. (a) shall also provide to the insured a good faith estimate of the insured's total
21out-of-pocket cost for the specified health care service provided by the specified
22provider.