Amendment ASA1-AB75

AB75-ASA1,1605,13 2. An individual major medical or comprehensive health benefit plan currently offered by the insurer with more limited benefits.

AB75-ASA1,1605,15 3. An individual major medical or comprehensive health benefit plan currently offered by the insurer with higher deductibles.

AB75-ASA1,1605,18 (b) Modify his or her existing coverage by electing an optional higher deductible, if any, under the individual major medical or comprehensive health benefit plan.

AB75-ASA1,1605,22 (3) (a) The insurer may not impose any new preexisting condition exclusion under the new or modified coverage under sub. (2) that did not apply to the insured's original coverage and shall allow the insured credit under the new or modified coverage for the period of original coverage.

AB75-ASA1,1605,25 (b) For the new or modified coverage, the insurer may not rate for health status other than on the insured's health status at the time the insured applied for the original coverage and as the insured disclosed on the original application.

AB75-ASA1,1606,3 (4) (a) Annually, the insurer shall mail to each insured under an individual major medical or comprehensive health benefit plan issued by the insurer, a notice that includes all of the following information:

AB75-ASA1,1606,5 1. That the insured has the right to elect alternative coverage as described in sub. (2).

AB75-ASA1,1606,6 2. A description of the alternatives available to the insured.

AB75-ASA1,1606,7 3. The procedure for making the election.

AB75-ASA1,1606,9 (b) The insurer shall mail the notice under par. (a) not more than 3 months nor less than 60 days before the renewal date of the insured's plan.

AB75-ASA1,1606,12 (5) (a) Nothing in this section requires an insurer to issue alternative coverage under sub. (2) if the insured's coverage may be nonrenewed or discontinued under s. 632.7495 (2), (3) (b), or (4).

AB75-ASA1,1606,16 (b) Notwithstanding s. 600.01 (1) (b) 3. and 4., this section applies to a group health benefit plan described in s. 600.01 (1) (b) 3. or 4. if that group health benefit plan is an individual major medical or comprehensive health benefit plan as defined in sub. (1).

AB75-ASA1, s. 3176 Section 3176. 632.76 (2) (ac) of the statutes is created to read:

AB75-ASA1,1606,23 632.76 (2) (ac) 1. Notwithstanding par. (a), no claim or loss incurred or disability commencing after 12 months from the date of issue of an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB75-ASA1,1607,4 2. Except as provided in subd. 3., an individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB75-ASA1,1607,7 3. Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy subject to s. 632.7495 (4) and (5):

AB75-ASA1,1607,11 a. The policy may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage.

AB75-ASA1,1607,17 b. The policy shall reduce the length of time during which a preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB75-ASA1, s. 3177 Section 3177. 632.76 (2) (b) of the statutes is amended to read:

AB75-ASA1,1608,11 632.76 (2) (b) Notwithstanding par. (a), no claim for loss incurred or disability commencing after 6 months from the date of issue of a medicare supplement policy, medicare replacement policy or long-term care insurance policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage. A Notwithstanding par. (ac) 2., a medicare supplement policy, medicare replacement policy, or long-term care insurance policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Notwithstanding par. (a), if on the basis of information contained in an application for insurance a medicare supplement policy, medicare replacement policy, or long-term care insurance policy excludes from coverage a condition by name or specific description, the exclusion must terminate no later than 6 months after the date of issue of the medicare supplement policy, medicare replacement policy, or long-term care insurance policy. The commissioner may by rule exempt from this paragraph certain classes of medicare supplement policies, medicare replacement policies, and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.

AB75-ASA1, s. 3178 Section 3178. 632.835 (title) of the statutes is amended to read:

AB75-ASA1,1608,14 632.835 (title) Independent review of adverse and experimental treatment coverage denial determinations.

AB75-ASA1, s. 3179 Section 3179. 632.835 (1) (ag) of the statutes is created to read:

AB75-ASA1,1608,18 632.835 (1) (ag) "Coverage denial determination" means an adverse determination, an experimental treatment determination, a preexisting condition exclusion denial determination, or the rescission of a policy or certificate.

AB75-ASA1, s. 3180 Section 3180. 632.835 (1) (cm) of the statutes is created to read:

AB75-ASA1,1608,23 632.835 (1) (cm) "Preexisting condition exclusion denial determination" means a determination by or on behalf of an insurer that issues a health benefit plan denying or terminating treatment or payment for treatment on the basis of a preexisting condition exclusion, as defined in s. 632.745 (23).

AB75-ASA1, s. 3181 Section 3181. 632.835 (2) (a) of the statutes is amended to read:

AB75-ASA1,1609,5 632.835 (2) (a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of an adverse determination or an experimental treatment a coverage denial determination made with respect to the insured.

AB75-ASA1, s. 3182 Section 3182. 632.835 (2) (b) of the statutes is amended to read:

AB75-ASA1,1609,14 632.835 (2) (b) If an adverse determination or an experimental treatment a coverage denial determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

AB75-ASA1, s. 3183 Section 3183. 632.835 (2) (bg) 3. of the statutes is amended to read:

AB75-ASA1,1609,25 632.835 (2) (bg) 3. For any adverse determination or experimental treatment coverage denial determination for which an explanation of benefits is not provided to the insured, the insurer provides a notice that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited, independent review with respect to an urgent matter. The notice shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under subd. 1. The notice shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.

AB75-ASA1, s. 3184 Section 3184. 632.835 (2) (c) of the statutes is amended to read:

AB75-ASA1,1610,7 632.835 (2) (c) Except as provided in par. (d), an insured must exhaust the internal grievance procedure under s. 632.83 before the insured may request an independent review under this section. Except as provided in sub. (9) (a), an insured who uses the internal grievance procedure must request an independent review as provided in sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under s. 632.83 (3) (d).

AB75-ASA1, s. 3185 Section 3185. 632.835 (2) (e) of the statutes is created to read:

AB75-ASA1,1610,10 632.835 (2) (e) Nothing in this section affects an insured's right to commence a civil proceeding relating to a coverage denial determination.

AB75-ASA1, s. 3186 Section 3186. 632.835 (3) (a) of the statutes is amended to read:

AB75-ASA1,1610,24 632.835 (3) (a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the insurer that made or on whose behalf was made the adverse or experimental treatment coverage denial determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. The insured or his or her authorized representative must pay a $25 fee to the independent review organization. If the insured prevails on the review, in whole or in part, the entire amount paid by the insured or his or her authorized representative shall be refunded by the insurer to the insured or his or her authorized representative. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

AB75-ASA1, s. 3187 Section 3187. 632.835 (3) (e) of the statutes is amended to read:

AB75-ASA1,1611,11 632.835 (3) (e) In addition to the information under pars. (b) and (c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and pars. (b) and (c). If, on the basis of any additional information, the insurer reconsiders the insured's grievance and determines that the treatment that was the subject of the grievance should be covered, or that the policy or certificate that was rescinded should be reinstated, the independent review is terminated.

AB75-ASA1, s. 3188 Section 3188. 632.835 (3) (f) of the statutes is renumbered 632.835 (3) (f) 1. and amended to read:

AB75-ASA1,1611,21 632.835 (3) (f) 1. If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer. A Except as provided in subd. 2., a decision of an independent review organization is binding on the insured and the insurer.

AB75-ASA1, s. 3189 Section 3189. 632.835 (3) (f) 2. of the statutes is created to read:

AB75-ASA1,1611,25 632.835 (3) (f) 2. A decision of an independent review organization regarding a preexisting condition exclusion denial determination or a rescission is not binding on the insured.

AB75-ASA1, s. 3190 Section 3190. 632.835 (3m) (a) of the statutes is amended to read:

AB75-ASA1,1612,5 632.835 (3m) (a) A decision of an independent review organization regarding an adverse determination or a preexisting condition exclusion denial determination must be consistent with the terms of the health benefit plan under which the adverse determination or preexisting condition exclusion denial determination was made.

AB75-ASA1, s. 3192 Section 3192. 632.835 (7) (b) of the statutes is amended to read:

AB75-ASA1,1612,11 632.835 (7) (b) A health benefit plan that is the subject of an independent review and the insurer that issued the health benefit plan shall not be liable to any person for damages attributable to the insurer's or plan's actions taken in compliance with any decision regarding an adverse determination or an experimental treatment determination rendered by a certified independent review organization.

AB75-ASA1, s. 3193 Section 3193. 632.835 (8) of the statutes is renumbered 632.835 (8) (a) and amended to read:

AB75-ASA1,1612,22 632.835 (8) (a) Adverse and experimental treatment determinations. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for adverse determinations and experimental treatment determinations and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to adverse determinations and experimental treatment determinations.

AB75-ASA1, s. 3194 Section 3194. 632.835 (8) (b) of the statutes is created to read:

AB75-ASA1,1613,7 632.835 (8) (b) Preexisting condition exclusion denials and rescissions. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for preexisting condition exclusion denial determinations and rescissions and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to preexisting condition exclusion denial determinations and rescissions.

AB75-ASA1, s. 3195 Section 3195. 632.835 (9) of the statutes is renumbered 632.835 (9) (a) and amended to read:

AB75-ASA1,1613,18 632.835 (9) (a) Adverse and experimental treatment determinations. The independent review required under this section with respect to an adverse determination or an experimental treatment determination shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000. Notwithstanding sub. (2) (c), an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000, but before June 15, 2002, with respect to an adverse determination or an experimental treatment determination must request an independent review no later than 4 months after June 15, 2002.

AB75-ASA1, s. 3196 Section 3196. 632.835 (9) (b) of the statutes is created to read:

AB75-ASA1,1613,25 632.835 (9) (b) Preexisting condition exclusion denials and rescissions. The independent review required under this section with respect to a preexisting condition exclusion denial determination or a rescission shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after the date stated in the notice published in the Wisconsin Administrative Register by the commissioner under sub. (8) (b).

AB75-ASA1, s. 3197 Section 3197. 632.845 of the statutes is created to read:

AB75-ASA1,1614,4 632.845 Prohibiting refusal to cover services because liability policy may cover. (1) In this section, "health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB75-ASA1,1614,8 (2) An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.

AB75-ASA1, s. 3197n Section 3197n. 632.87 (4) of the statutes is amended to read:

AB75-ASA1,1614,14 632.87 (4) No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed dentist within the scope of the dentist's license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by another health care provider, as defined in s. 146.81 (1) (a) to (p).

AB75-ASA1, s. 3197r Section 3197r. 632.89 (1) (dm) of the statutes is created to read:

AB75-ASA1,1614,18 632.89 (1) (dm) "Licensed mental health professional" means a clinical social worker who is licensed under ch. 457, a marriage and family therapist who is licensed under s. 457.10, or a professional counselor who is licensed under s. 457.12.

AB75-ASA1, s. 3197s Section 3197s. 632.89 (1) (e) 3. of the statutes is repealed and recreated to read:

AB75-ASA1,1614,21 632.89 (1) (e) 3. A psychologist licensed under ch. 455.

AB75-ASA1, s. 3197t Section 3197t. 632.89 (1) (e) 4. of the statutes is created to read:

AB75-ASA1,1614,24 632.89 (1) (e) 4. A licensed mental health professional practicing within the scope of his or her license under ch. 457 and applicable rules.

AB75-ASA1, s. 3197w Section 3197w. 632.895 (12m) of the statutes is created to read:

AB75-ASA1,1615,2 632.895 (12m) Treatment for autism spectrum disorders. (a) In this subsection:

AB75-ASA1,1615,3 1. "Autism spectrum disorder" means any of the following:

AB75-ASA1,1615,4 a. Autism disorder.

AB75-ASA1,1615,5 b. Asperger's syndrome.

AB75-ASA1,1615,6 c. Pervasive developmental disorder not otherwise specified.

AB75-ASA1,1615,8 2. "Insured" includes an enrollee and a dependent with coverage under the disability insurance policy or self-insured health plan.

AB75-ASA1,1615,11 3. "Intensive-level services" means evidence-based behavioral therapy that is designed to help an individual with autism spectrum disorder overcome the cognitive, social, and behavioral deficits associated with that disorder.

AB75-ASA1,1615,16 4. "Nonintensive-level services" means therapy that occurs after the completion of treatment with intensive-level services and that is designed to sustain and maximize gains made during treatment with intensive-level services or, for an individual who has not and will not receive intensive-level services, therapy that will improve the individual's condition.

AB75-ASA1,1615,17 5. "Physician" has the meaning given in s. 146.34 (1) (g).

AB75-ASA1,1615,23 (b) Subject to pars. (c) and (d), and except as provided in par. (e), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, shall provide coverage for an insured of treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician and provided by any of the following who are qualified to provide intensive-level services or nonintensive-level services:

AB75-ASA1,1615,24 1. A psychiatrist, as defined in s. 146.34 (1) (h).

AB75-ASA1,1615,25 2. A person who practices psychology, as described in s. 455.01 (5).

AB75-ASA1,1616,2 3. A social worker, as defined in s. 252.15 (1) (er), who is certified or licensed to practice psychotherapy, as defined in s. 457.01 (8m).

AB75-ASA1,1616,4 4. A paraprofessional working under the supervision of a provider listed under subds. 1. to 3.

AB75-ASA1,1616,6 5. A professional working under the supervision of an outpatient mental health clinic certified under s. 51.038.

AB75-ASA1,1616,7 6. A speech-language pathologist, as defined in s. 459.20 (4).

AB75-ASA1,1616,8 7. An occupational therapist, as defined in s. 448.96 (4).

AB75-ASA1,1616,17 (c) 1. The coverage required under par. (b) shall provide at least $60,000 for intensive-level services per insured per year, with a minimum of 30 to 35 hours of care per week for a minimum duration of 4 years, and at least $30,000 for nonintensive-level services per insured per year, except that these minimum coverage monetary amounts shall be adjusted annually, beginning in 2011, to reflect changes in the consumer price index for all urban consumers, U.S. city average, for the medical care group, as determined by the U.S. department of labor. The commissioner shall publish the new minimum coverage amounts under this subdivision each year, beginning in 2011, in the Wisconsin Administrative Register.

AB75-ASA1,1616,21 2. Notwithstanding subd. 1., the minimum coverage monetary amounts or duration required for treatment under subd. 1., need not be met if it is determined by a supervising professional, in consultation with the insured's physician, that less treatment is medically appropriate.

AB75-ASA1,1616,25 (d) The coverage required under par. (b) may be subject to deductibles, coinsurance, or copayments that generally apply to other conditions covered under the policy or plan. The coverage may not be subject to limitations or exclusions, including limitations on the number of treatment visits.

AB75-ASA1,1616,26 (e) This subsection does not apply to any of the following: