LRBs0258/1
PJK:jld:md
2009 - 2010 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2009 SENATE BILL 362
January 27, 2010 - Offered by Senator Hansen.
SB362-SSA1,2,2
1An Act to repeal 632.89 (2) (a) 2., 632.89 (2) (b), 632.89 (2) (c) 2., 632.89 (2) (d)
22., 632.89 (2) (dm) 2., 632.89 (3m), 632.89 (6) and 632.89 (7);
to renumber
3632.89 (2m), 632.89 (4) and 632.89 (5);
to renumber and amend 632.89 (2) (a)
41., 632.89 (2) (c) 1., 632.89 (2) (d) 1., 632.89 (2) (dm) 1. and 632.89 (2) (e);
to
5amend 40.51 (8), 40.51 (8m), 46.10 (8) (d), 46.10 (14) (a), 49.345 (8) (d), 49.345
6(14) (a), 66.0137 (4), 120.13 (2) (g), 185.981 (4t), 185.983 (1) (intro.), 301.12 (8)
7(d), 301.12 (14) (a), 632.89 (title) and 632.89 (2) (title);
to repeal and recreate
8632.89 (1) (b), 632.89 (1) (em), 632.89 (4) (title) and 632.89 (5) (title); and
to
9create 111.91 (2) (qm), 609.71, 632.89 (1) (at), 632.89 (3), 632.89 (3c), 632.89
10(3f), 632.89 (3p), 632.89 (4) (b), 632.89 (5) (a) (title) and 632.89 (5) (c) of the
11statutes;
relating to: health insurance coverage of nervous and mental
1disorders, alcoholism, and other drug abuse problems; providing an exemption
2from emergency rule procedures; and granting rule-making authority.
Analysis by the Legislative Reference Bureau
Under current law, a group health insurance policy (called a "disability
insurance policy" in the statutes) that provides coverage of any inpatient hospital
services must cover those services for the treatment of nervous and mental disorders
(mental health) and alcoholism and other drug abuse problems (substance abuse
problems) in the minimum amount of the lesser of: 1) the expenses of 30 days of
inpatient services; or 2) $7,000 minus the applicable cost sharing under the policy
or, if there is no cost sharing under the policy, $6,300 in equivalent benefits measured
in services rendered. If a group health insurance policy provides coverage of any
outpatient hospital services, it must cover those services for the treatment of mental
health and substance abuse problems in the minimum amount of $2,000 minus the
applicable cost sharing under the policy or, if there is no cost sharing under the policy,
$1,800 in equivalent benefits measured in services rendered. If a group health
insurance policy provides coverage of any inpatient or outpatient hospital services,
it must cover the cost of transitional treatment arrangements for the treatment of
mental health and substance abuse problems in the minimum amount of $3,000
minus the applicable cost sharing under the policy or, if there is no cost sharing under
the policy, $2,700 in equivalent benefits measured in services rendered. Transitional
treatment arrangements include services, specified by rule by the commissioner of
insurance, that are provided in a less restrictive manner than inpatient services but
in a more intensive manner than outpatient services. If a group health insurance
policy provides coverage for both inpatient and outpatient hospital services, the total
coverage for all types of treatment for mental health and substance abuse problems
is not required to exceed $7,000, or the equivalent benefits measured in services
rendered, in a policy year.
This substitute amendment removes the specified minimum amounts of
coverage that a group health insurance policy must provide for the treatment of
mental health and substance abuse problems but retains the requirements with
respect to providing the coverage. Except for group plans providing limited benefits,
the substitute amendment specifically applies the requirements to all types of group
health benefit plans, including defined network plans, insurance plans offered by the
state, and governmental self-insured health plans of the state and municipalities.
The substitute amendment requires that deductibles, copayments,
out-of-pocket limits, limitations regarding referrals to nonphysicians, and other
treatment limitations under a group health benefit plan or a governmental
self-insured health plan, or under an individual health benefit plan that provides
coverage of treatment for mental health or substance abuse problems, may not be
more restrictive with respect to that coverage than the most common or frequent type
of treatment limitations that apply to substantially all other coverage under the
plan. The substitute amendment also requires that expenses incurred for the
treatment of mental health and substance abuse problems be included in any overall
deductible amount, annual or lifetime limit, or out-of-pocket limit under the plan.
The substitute amendment provides two exceptions to these equal coverage
requirements. If, as a result of the new requirements, the total cost of coverage to
an employer under a group health benefit plan or a governmental self-insured
health plan for the treatment of mental health and substance abuse problems
increases by more than 2 percent in the first plan year that the requirements apply,
or by 1 percent in any plan year thereafter, the employer may elect for the employer's
plan to be exempt during the following plan year from the new requirements and
subject to the requirements for coverage of the treatment of mental health and
substance abuse problems under current law. The cost increase must be determined
by a qualified actuary. The second exception is for employers with fewer than ten
employees. Any such employer may elect for the employer's plan to be exempt during
a plan year from the new requirements and subject to the requirements under
current law.
Finally, the substitute amendment requires a group health benefit plan or a
governmental self-insured health plan, or an individual health benefit plan that
provides coverage of treatment for mental health or substance abuse problems, to
make available to an insured or plan participant upon request: 1) the plan's criteria
for determining medical necessity for coverage of that treatment; and 2) the reason
for any denial of coverage for services for that treatment. Current law requires an
insurer that restricts or terminates an insured's coverage that results in the
insured's liability for the cost of the treatment to provide on the explanation of
benefits form an explanation of the clinical rationale for the restriction or
termination of coverage.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB362-SSA1,3,63
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, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to
6(6), 632.885,
632.89, 632.895 (5m) and (8) to (17), and 632.896.
SB362-SSA1,4,4
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, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885,
632.89, and 632.895
4(11) to (17).
SB362-SSA1,4,106
46.10
(8) (d) After due regard to the case and to a spouse and minor children
7who are lawfully dependent on the property for support, compromise or waive any
8portion of any claim of the state or county for which a person specified under sub. (2)
9is liable, but not any claim payable by an insurer under s. 632.89 (2) or
(2m) (4m) or
10by any other 3rd party.
SB362-SSA1, s. 4
11Section
4. 46.10 (14) (a) of the statutes is amended to read:
SB362-SSA1,5,212
46.10
(14) (a) Except as provided in pars. (b) and (c), liability of a person
13specified in sub. (2) or s. 46.03 (18) for inpatient care and maintenance of persons
14under 18 years of age at community mental health centers, a county mental health
15complex under s. 51.08, the centers for the developmentally disabled, the Mendota
16Mental Health Institute, and the Winnebago Mental Health Institute or care and
17maintenance of persons under 18 years of age in residential, nonmedical facilities
18such as group homes, foster homes, treatment foster homes, subsidized
19guardianship homes, residential care centers for children and youth, and juvenile
20correctional institutions is determined in accordance with the cost-based fee
21established under s. 46.03 (18). The department shall bill the liable person up to any
22amount of liability not paid by an insurer under s. 632.89 (2) or
(2m) (4m) or by other
233rd-party benefits, subject to rules that include formulas governing ability to pay
24promulgated by the department under s. 46.03 (18). Any liability of the patient not
1payable by any other person terminates when the patient reaches age 18, unless the
2liable person has prevented payment by any act or omission.
SB362-SSA1,5,84
49.345
(8) (d) After due regard to the case and to a spouse and minor children
5who are lawfully dependent on the property for support, compromise or waive any
6portion of any claim of the state or county for which a person specified under sub. (2)
7is liable, but not any claim payable by an insurer under s. 632.89 (2) or
(2m) (4m) or
8by any other 3rd party.
SB362-SSA1, s. 6
9Section
6. 49.345 (14) (a) of the statutes is amended to read:
SB362-SSA1,5,2010
49.345
(14) (a) Except as provided in pars. (b) and (c), liability of a person
11specified in sub. (2) or s. 49.32 (1) for care and maintenance of persons under 18 years
12of age in residential, nonmedical facilities such as group homes, foster homes,
13treatment foster homes, subsidized guardianship homes, and residential care
14centers for children and youth is determined in accordance with the cost-based fee
15established under s. 49.32 (1). The department shall bill the liable person up to any
16amount of liability not paid by an insurer under s. 632.89 (2) or
(2m) (4m) or by other
173rd-party benefits, subject to rules that include formulas governing ability to pay
18established by the department under s. 49.32 (1). Any liability of the person not
19payable by any other person terminates when the person reaches age 18, unless the
20liable person has prevented payment by any act or omission.
SB362-SSA1,6,323
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
24a village provides health care benefits under its home rule power, or if a town
25provides health care benefits, to its officers and employees on a self-insured basis,
1the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
2632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.85, 632.853, 632.855, 632.87 (4), (5),
3and (6), 632.885,
632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
SB362-SSA1, s. 8
4Section
8. 111.91 (2) (qm) of the statutes is created to read:
SB362-SSA1,6,75
111.91
(2) (qm) The requirements under s. 632.89 relating to coverage of
6treatment for nervous and mental disorders and alcoholism and other drug
7problems.
SB362-SSA1,6,1310
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
1149.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
12632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885,
632.89, 632.895 (9) to (17),
13632.896, and 767.513 (4).
SB362-SSA1,6,1916
185.981 (4t) A sickness care plan operated by a cooperative association is
17subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.85,
18632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885,
632.89, 632.895 (10) to
19(17), and 632.897 (10) and chs. 149 and 155.
SB362-SSA1,7,322
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, 632.85, 632.853,
1632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885,
632.89, 632.895 (5) and (9) to (17),
2632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring
3association shall:
SB362-SSA1,7,95
301.12
(8) (d) After due regard to the case and to a spouse and minor children
6who are lawfully dependent on the property for support, compromise or waive any
7portion of any claim of the state or county for which a person specified under sub. (2)
8is liable, but not any claim payable by an insurer under s. 632.89 (2) or
(2m) (4m) or
9by any other 3rd party.
SB362-SSA1,7,2111
301.12
(14) (a) Except as provided in pars. (b) and (c), liability of a person
12specified in sub. (2) or s. 301.03 (18) for care and maintenance of persons under 17
13years of age in residential, nonmedical facilities such as group homes, foster homes,
14treatment foster homes, residential care centers for children and youth and juvenile
15correctional institutions is determined in accordance with the cost-based fee
16established under s. 301.03 (18). The department shall bill the liable person up to
17any amount of liability not paid by an insurer under s. 632.89 (2) or
(2m) (4m) or by
18other 3rd-party benefits, subject to rules which include formulas governing ability
19to pay promulgated by the department under s. 301.03 (18). Any liability of the
20resident not payable by any other person terminates when the resident reaches age
2117, unless the liable person has prevented payment by any act or omission.
SB362-SSA1,7,24
23609.71 Coverage of alcoholism and other diseases. Defined network
24plans are subject to s. 632.89.
SB362-SSA1,8,2
1632.89 (title)
Required coverage of Coverage of mental disorders,
2alcoholism, and other diseases.
SB362-SSA1,8,54
632.89
(1) (at) "Group health benefit plan" has the meaning given in s. 632.745
5(9).
SB362-SSA1, s. 17
6Section
17. 632.89 (1) (b) of the statutes is repealed and recreated to read:
SB362-SSA1,8,77
632.89
(1) (b) "Health benefit plan" has the meaning given in s. 632.745 (11).
SB362-SSA1, s. 18
8Section
18. 632.89 (1) (em) of the statutes is repealed and recreated to read:.
SB362-SSA1,8,109
632.89
(1) (em) "Self-insured health plan" has the meaning given in s. 632.745
10(24).
SB362-SSA1, s. 19
11Section
19. 632.89 (2) (title) of the statutes is amended to read:
SB362-SSA1,8,1212
632.89
(2) (title)
Required coverage
for group plans.
SB362-SSA1, s. 20
13Section
20. 632.89 (2) (a) 1. of the statutes is renumbered 632.89 (2) (a) and
14amended to read: