Amendment SSA1-AB75

AB75-SSA1,1612,5 632.835 (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-SSA1, s. 3192 Section 3192. 632.835 (7) (b) of the statutes is amended to read:

AB75-SSA1,1612,11 632.835 (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-SSA1, s. 3193 Section 3193. 632.835 (8) of the statutes is renumbered 632.835 (8) (a) and amended to read:

AB75-SSA1,1612,22 632.835 (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-SSA1, s. 3194 Section 3194. 632.835 (8) (b) of the statutes is created to read:

AB75-SSA1,1613,7 632.835 (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-SSA1, s. 3195 Section 3195. 632.835 (9) of the statutes is renumbered 632.835 (9) (a) and amended to read:

AB75-SSA1,1613,18 632.835 (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-SSA1, s. 3196 Section 3196. 632.835 (9) (b) of the statutes is created to read:

AB75-SSA1,1613,25 632.835 (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-SSA1, s. 3197 Section 3197. 632.845 of the statutes is created to read:

AB75-SSA1,1614,4 632.845 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-SSA1,1614,8 (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-SSA1, s. 3197n Section 3197n. 632.87 (4) of the statutes is amended to read:

AB75-SSA1,1614,14 632.87 (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-SSA1, s. 3197r Section 3197r. 632.89 (1) (dm) of the statutes is created to read:

AB75-SSA1,1614,18 632.89 (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-SSA1, s. 3197s Section 3197s. 632.89 (1) (e) 3. of the statutes is repealed and recreated to read:

AB75-SSA1,1614,21 632.89 (1) (e) 3. A psychologist licensed under ch. 455.

AB75-SSA1, s. 3197t Section 3197t. 632.89 (1) (e) 4. of the statutes is created to read:

AB75-SSA1,1614,24 632.89 (1) (e) 4. A licensed mental health professional practicing within the scope of his or her license under ch. 457 and applicable rules.

AB75-SSA1, s. 3197w Section 3197w. 632.895 (12m) of the statutes is created to read:

AB75-SSA1,1615,2 632.895 (12m) Treatment for autism spectrum disorders. (a) In this subsection:

AB75-SSA1,1615,3 1. "Autism spectrum disorder" means any of the following:

AB75-SSA1,1615,4 a. Autism disorder.

AB75-SSA1,1615,5 b. Asperger's syndrome.

AB75-SSA1,1615,6 c. Pervasive developmental disorder not otherwise specified.

AB75-SSA1,1615,8 2. "Insured" includes an enrollee and a dependent with coverage under the disability insurance policy or self-insured health plan.

AB75-SSA1,1615,11 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-SSA1,1615,16 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-SSA1,1615,17 5. "Physician" has the meaning given in s. 146.34 (1) (g).

AB75-SSA1,1615,23 (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-SSA1,1615,24 1. A psychiatrist, as defined in s. 146.34 (1) (h).

AB75-SSA1,1615,25 2. A person who practices psychology, as described in s. 455.01 (5).

AB75-SSA1,1616,2 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-SSA1,1616,4 4. A paraprofessional working under the supervision of a provider listed under subds. 1. to 3.

AB75-SSA1,1616,6 5. A professional working under the supervision of an outpatient mental health clinic certified under s. 51.038.

AB75-SSA1,1616,7 6. A speech-language pathologist, as defined in s. 459.20 (4).

AB75-SSA1,1616,8 7. An occupational therapist, as defined in s. 448.96 (4).

AB75-SSA1,1616,17 (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-SSA1,1616,21 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-SSA1,1616,25 (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-SSA1,1616,26 (e) This subsection does not apply to any of the following:

AB75-SSA1,1617,2 1. A disability insurance policy that covers only certain specified diseases.

AB75-SSA1,1617,5 2. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB75-SSA1,1617,6 3. A long-term care insurance policy.

AB75-SSA1,1617,7 4. A medicare replacement policy or a medicare supplement policy.

AB75-SSA1,1617,12 (f) 1. The commissioner shall by rule further define "intensive-level services" and "nonintensive-level services" and define "paraprofessional" for purposes of par. (b) 4. and "qualified" for purposes of providing services under this subsection. The commissioner may promulgate rules governing the interpretation or administration of this subsection.

AB75-SSA1,1617,20 2. Using the procedure under s. 227.24, the commissioner may promulgate the rules under subd. 1. for the period before the effective date of the permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the commissioner is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.

AB75-SSA1, s. 3198 Section 3198. 632.895 (14m) of the statutes is created to read:

AB75-SSA1,1617,25 632.895 (14m) Coverage of dependents. (a) Subject to par. (b), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a person as a dependent of an insured shall provide dependent coverage for a child of an insured.

AB75-SSA1,1618,2 (b) A policy or plan is not required to provide dependent coverage for a child of an insured if any of the following applies:

AB75-SSA1,1618,3 1. The child is 27 years of age or older.

AB75-SSA1,1618,4 2. The child is married.

AB75-SSA1,1618,5 3. The child has other health care coverage.

AB75-SSA1,1618,7 4. The child is employed full time and his or her employer offers health care coverage to its employees.

AB75-SSA1,1618,9 5. Coverage of the insured through whom the child has dependent coverage under the policy or plan is discontinued or not renewed.

AB75-SSA1, s. 3198d Section 3198d. 632.895 (17) of the statutes is created to read:

AB75-SSA1,1618,13 632.895 (17) Contraceptives and services. (a) In this subsection, "contraceptives" means drugs or devices approved by the federal food and drug administration to prevent pregnancy.

AB75-SSA1,1618,17 (b) Every disability insurance policy, and every self-insured health plan of the state or of a county, city, town, village, or school district, that provides coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices shall provide coverage for all of the following:

AB75-SSA1,1618,19 1. Contraceptives prescribed by a health care provider, as defined in s. 146.81 (1).

AB75-SSA1,1618,22 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan.

AB75-SSA1,1619,2 (c) Coverage under par. (b) may be subject only to the exclusions, limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan.

AB75-SSA1,1619,3 (d) This subsection does not apply to any of the following:

AB75-SSA1,1619,4 1. A disability insurance policy that covers only certain specified diseases.

AB75-SSA1,1619,7 2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.

AB75-SSA1,1619,10 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB75-SSA1,1619,11 4. A long-term care insurance policy.

AB75-SSA1,1619,12 5. A Medicare replacement policy or a Medicare supplement policy.

AB75-SSA1, s. 3199 Section 3199. Chapter 648 of the statutes is created to read:

AB75-SSA1,1619,14 CHAPTER 648

AB75-SSA1,1619,16 Regulation of Care Management Organizations

AB75-SSA1,1619,17 648.01 Definitions. In this chapter:

AB75-SSA1,1619,19 (1) "Care management organization" means an entity described in s. 46.284 (3m).

AB75-SSA1,1619,20 (2) "Department" means the department of health services.

AB75-SSA1,1619,21 (3) "Enrollee" has the meaning given in s. 46.2805 (3).

AB75-SSA1,1619,23 (4) "Permittee" means a care management organization issued a permit under this chapter.

AB75-SSA1,1619,25 648.03 Applicability of other laws. Notwithstanding s. 600.01 (1) (b) 10. a., ss. 600.01, 600.02, 600.03, and 600.12 apply to this chapter.

AB75-SSA1,1620,3 648.05 Permit. (1) Permit required. After December 31, 2009, no care management organization may provide services to its enrollees without a permit under this chapter.

AB75-SSA1,1620,5 (2) Application. A care management organization applying for a permit shall submit all of the following information in the format required by the commissioner:

AB75-SSA1,1620,8 (a) The names, addresses and occupations of all controlling persons and directors and principal officers of the care management organization currently and for the preceding 10 years, unless the commissioner waives this requirement.

AB75-SSA1,1620,10 (b) Business organization documents, including articles and bylaws if applicable.

AB75-SSA1,1620,13 (c) A business plan approved by the department, including a projection of the anticipated operating results at the end of each of the next 3 years of operation, based on reasonable estimates of income and operating expenses.

AB75-SSA1,1620,15 (d) Any other relevant documents or information that the commissioner reasonably requires after consulting with the department.

AB75-SSA1,1620,18 (3) Standards for issuing permit. The commissioner may issue a permit to the care management organization if the commissioner finds, after consulting with the department, all of the following:

AB75-SSA1,1620,19 (a) All requirements of law have been met.

AB75-SSA1,1620,23 (b) All the directors and principal officers or any controlling person are trustworthy and competent and collectively have the competence and experience to engage in the proposed services and are not excluded from participation under 42 USC 1320a-7 or 42 USC 1320a-7a.

AB75-SSA1,1620,25 (c) The business plan is consistent with the interests of the care management organization's enrollees and the public.