SB337: Bill Text

LRB-3210/1

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2007 - 2008 LEGISLATURE

2007 Senate BILL 337

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 An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.981 (4t) and 185.983 (1) (intro.); and to create 146.903, 609.71 and 632.798 of the statutes; relating to: disclosure of information by health care providers and insurers.

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 Section 1. 40.51 (8) of the statutes is amended to read:

SB337,2,5 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (6), 632.895 (5m) and (8) to (14), and 632.896.

SB337, s. 2 Section 2. 40.51 (8m) of the statutes is amended to read:

SB337,3,3 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to (14).

SB337, s. 3 Section 3. 66.0137 (4) of the statutes is amended to read:

SB337,3,10 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.895 (9) to (14), 632.896, and 767.513 (4).

SB337, s. 4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

SB337,3,15 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.895 (9) to (14), 632.896, and 767.513 (4).

SB337, s. 5 Section 5. 146.903 of the statutes is created to read:

SB337,3,18 146.903 Disclosures required of health care providers. (1) In this section:

SB337,3,19 (a) "Ambulatory surgery center" has the meaning given in 42 CFR 416.2.

SB337,3,22 (b) "Clinic" means a place, other than a residence, that is used primarily for the provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and treatment.

SB337,3,24 (c) "Diagnosis-related groups" means a classification of inpatient hospital discharges specified under 42 CFR 412.60.

SB337,4,2 (d) "Health care provider" has the meaning given in s. 146.81 (1) and includes a clinic and an ambulatory surgery center.

SB337,4,4 (e) "Medical Assistance" means health care benefits provided under subch. IV of ch. 49.

SB337,4,8 (f) "Usual and customary charge" means the amount that a health care provider usually and customarily charges for a health care service, diagnostic test, or procedure, before any discount or contractual rate applicable to certain patients or payers is applied.

SB337,4,11 (2) Except as provided in sub. (5), a health care provider or the health care provider's designee shall, upon request by and at no cost to a health care consumer, disclose to the consumer all of the following, under the following circumstances:

SB337,4,15 (a) Within a reasonable period of time after the request, the usual and customary charges, assuming no medical complications, for an inpatient or outpatient health care service, diagnostic test, or procedure that is specified by the consumer and that is provided by the health care provider.

SB337,4,17 (b) Immediately upon request, on the site of the health care provider, as a single document, all of the following:

SB337,4,22 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. The information under this subdivision shall be classified as follows:

SB337,4,24 a. If provided concerning inpatient or outpatient services by a hospital, in the form of diagnosis-related groups.

SB337,5,4 b. If provided by a physician, in the form of presenting conditions, including the total charges for codes under the Current Procedural Terminology of the American Medical Association that are most frequently performed as a result of the presenting conditions.

SB337,5,12 c. If provided by a health care provider other than a hospital or physician, in a grouping form similar to that under subd. 1. a. or b. Notwithstanding the requirement under subd. 1. (intro.) that 50 health care services, diagnostic tests, or procedures be disclosed, if the health care provider under this subd. 1. c. performs fewer than 50 health care services, diagnostic tests, or procedures on a regular basis, the health care provider shall indicate that fact and disclose those health care services, diagnostic tests, or procedures that the health care provider performs on a regular basis.

SB337,5,16 2. If the health care provider is certified as a provider of Medical Assistance, the Medical Assistance payment rates, as specified on the Web site of the department, for the provider for the health care services, diagnostic tests, or procedures specified in subd. 1.

SB337,5,18 3. The average allowable payment from private, 3rd party payers for the health care services, diagnostic tests, or procedures specified in subd. 1.

SB337,5,20 4. The average of the charges and payment rates specified in subd. 1., 2., and 3. for each health care service, diagnostic test, or procedure specified in subd. 1.

SB337,5,23 (3) Information on charges or payment rates that is provided to a health care consumer under sub. (2) shall be updated annually by the health care provider and may not be construed as a legally binding estimate of the cost to the consumer.

SB337,6,5 (4) Except as provided in sub. (5), a health care provider shall prominently display, in the area of the health care provider's practice or facility that is most commonly frequented by health care consumers, a statement informing the consumers that they have the right to request charge or payment rate information for health care services, diagnostic tests, or procedures from the health care provider or, under s. 632.798, all of the following from their insurers or self-insured health plans:

SB337,6,8 (a) 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.

SB337,6,10 (b) A good faith estimate of the insured's total out-of-pocket cost for the specified health care service provided by the specified provider.

SB337,6,11 (5) This section does not apply to any of the following:

SB337,6,13 (a) A health care provider that practices individually and not in association with another health care provider.

SB337,6,15 (b) Health care providers that are an association of 3 or fewer individual health care providers.

SB337, s. 6 Section 6. 185.981 (4t) of the statutes is amended to read:

SB337,6,20 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.798, 632.85, 632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.895 (10) to (14), and 632.897 (10) and chs. 149 and 155.

SB337, s. 7 Section 7. 185.983 (1) (intro.) of the statutes is amended to read:

SB337,7,3 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85, 632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.895 (5) and (9) to (14), 632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring association shall: