2009 - 2010 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2009 SENATE BILL 418
February 2, 2010 - Offered by Senator Sullivan.
1An Act to amend
40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 153.21 (title), 2
185.981 (4t) and 185.983 (1) (intro.); and to create
146.903, 153.21 (3), 609.71 3
and 632.798 of the statutes; relating to: disclosure of information by health
4care providers, hospitals, and insurers and providing a penalty.
Analysis by the Legislative Reference Bureau
This substitute amendment requires a health care provider to disclose to a
consumer the provider's median billed charge for a health care service, diagnostic
test, or procedure, upon request. For purposes of the substitute amendment, a health
care provider includes a physician, nurse, dentist, chiropractor, physical therapist,
optometrist, pharmacist, psychologist, and clinic, among others, but does not include
a hospital. However, the substitute amendment exempts health care providers that
practice individually or in a group of less than three providers from the requirement
to provide charge information for a particular service, test, or procedure.
The substitute amendment also requires both health care providers and
hospitals to create a document that lists the following charge information for a
specified set of conditions or procedures: 1) the provider's median billed charge; 2)
the reimbursement amount under Medicare, except in the case of a provider who
does not participate in Medicare; and 3) the average allowable payment from private,
third-party payers. For health care providers, DHS must identify, by type of health
care provider, the 25 presenting conditions for which each type of provider most
frequently provides health care services, and these are the conditions for which a
health care provider must list charge information in the required document.
Hospitals are required to list the charge information for the 75 conditions for which
hospitals in this state most frequently provide inpatient care, as well as for the 75
outpatient surgical procedures that hospitals in this state most frequently perform.
Health care providers and hospitals must, upon request, provide consumers a copy
of their document listing charge information for the specified set of conditions or
procedures. The substitute amendment exempts health care providers that practice
individually or in a group of less than three providers from the requirement to create
a document listing charges.
Under the substitute amendment, 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 insured's or enrollee's total out-of-pocket cost for a specified health
care service in the geographic region in which the service will be provided. The
estimate must be provided only if the insured or enrollee requests it, and it must be
provided at no charge to the insured or enrollee. Before providing the estimate, the
insurer or self-insured health plan may require the insured or enrollee to provide,
in writing, the name of the provider providing the service, the facility at which the
service will be provided, the date the service will be provided, the provider's estimate
of the charges, and the Current Procedural Terminology code or Current Dental
Terminology code for the service. The substitute amendment specifies that the
estimate is not legally binding and is to be provided as of the date of the request and
assuming no medical complications or changes to the insured's or enrollee's
treatment plan. In addition, an insurer or self-insured plan is not required to
provide an estimate if the provider providing the health care service practices alone
or in association with only one or two other health care providers or is an association
of three or fewer health care providers.
Under the substitute amendment a health care provider or hospital must
prominently display notice regarding the availability of charge information that
providers or hospitals are required to disclose and of the requirement that a insurer
or self-insured health plan provide an an estimate of an insured's or enrollees
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
Every health care coverage plan offered by the state under sub. (6) 2
shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) 3
and (10), 632.747, 632.748, 632.798,
632.83, 632.835, 632.85, 632.853, 632.855, 4
632.87 (3) to (6), 632.885, 632.895 (5m) and (8) to (17), and 632.896.
Every health care coverage plan offered by the group insurance 8
board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 9
632.83, 632.835, 632.85, 632.853, 632.855, 632.885, and 632.895 10
(11) to (17).
66.0137 (4) Self-insured health plans.
If a city, including a 1st class city, or 14
a village provides health care benefits under its home rule power, or if a town 15
provides health care benefits, to its officers and employees on a self-insured basis, 16
the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 17
632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798,
632.85, 632.853, 632.855, 632.87 18
(4), (5), and (6), 632.885, 632.895 (9) to (17), 632.896, and 767.513 (4).
(g) Every self-insured plan under par. (b) shall comply with ss. 22
49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 23632.798,
632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.895 (9) to 24
(17), 632.896, and 767.513 (4).
1146.903 Disclosures required of health care providers and hospitals. 2(1) Definitions.
In this section:
(a) "Ambulatory surgical center" has the meaning given in 42 CFR 416.2
(b) "Clinic" means a place, other than a residence or a hospital, that is used 5
primarily for the provision of nursing, medical, podiatric, dental, chiropractic, or 6
optometric care and treatment.
(c) "Health care provider" has the meaning given in s. 146.81 (1) (a) to (L) and 8
includes a clinic and an ambulatory surgical center but does not include a nursing 9
home, as defined in s. 50.01 (3).
(d) "Hospital" has the meaning given in s. 50.33 (2).
(e) "Median billed charge" means one of the following:
1. For a health care provider, the amount the health care provider charged, 13
before any discount or contractual rate applicable to certain patients or payers was 14
applied, during the first 2 calendar quarters of the most recently completed calendar 15
year, as calculated by arranging the charges in that reporting period from highest 16
to lowest and selecting the middle charge in the sequence or, for an even number of 17
charges, selecting the 2 middle charges in the sequence and calculating the average 18
of the 2.
2. For a hospital, the amount the hospital charged, before any discount or 20
contractual rate applicable to certain patients or payers was applied, during the 4 21
calendar quarters for which the hospital most recently reported data under ch. 153, 22
as calculated by arranging the charges in the reporting period from highest to lowest 23
and selecting the middle charge in the sequence or, for an even number of charges, 24
selecting the 2 middle charges in the sequence and calculating the average of the 2.
(f) "Medicare" means coverage under part A or part B of Title XVIII of the 2
federal Social Security Act, 42 USC 1395
3(2) Department duties.
(a) The department shall do all of the following:
1. Categorize health care providers by type.
2. For each type of health care provider, annually identify the 25 presenting 6
conditions for which that type of health care provider most frequently provides 7
health care services.
3. Prescribe the methods by which health care providers shall calculate and 9
present median billed charges and Medicare and private 3rd-party payer payments 10
under sub. (3) (b).
(b) In performing the duties under par. (a), the department shall consult with 12
organizations in this state that do all of the following:
1. Develop performance measures for assessing the quality of health care 14
2. Guide the collection, validation, and analysis of data related to measures 16
described under subd. 1.
3. Report results of assessments of the quality of health care services.
4. Share best practices of organizations that provide health care services.
19(3) Health care provider disclosure of charges.
(a) Except as provided in 20
par. (g), a health care provider or the health care provider's designee shall, upon 21
request by and at no cost to a health care consumer, disclose to the consumer within 22
a reasonable period of time after the request, the median billed charge, assuming no 23
medical complications, for a health care service, diagnostic test, or procedure that is 24
specified by the consumer and that is provided by the health care provider.
(b) Except as provided in par. (g), a health care provider shall prepare a single 2
document that lists the following charge information, assuming no medical 3
complications, for diagnosing and treating each of the 25 presenting conditions 4
identified for the health care provider's provider type under sub. (2):
1. The median billed charge.
2. If the health care provider is certified as a provider of Medicare, the Medicare 7
payment to the provider.
3. The average allowable payment from private, 3rd-party payers.
(c) Except as provided in par. (g), a health care provider or the health care 10
provider's designee shall, upon request by and at no cost to a health care consumer, 11
provide the consumer a copy of the document prepared under par. (b).
(d) Except as provided in par. (g), a health care provider shall annually update 13
the document under par. (b).
(e) Information provided upon request under par. (a) or included on the 15
document under par. (b) does not constitute a legally binding estimate of the charge 16
for a specific patient or the amount that a 3rd-party payer will pay on behalf of the 17
(f) Except as provided in par. (g), a health care provider shall prominently 19
display, in the area of the health care provider's practice or facility that is most 20
commonly frequented by health care consumers, a statement informing the 21
consumers that they have the right to receive charge information as provided in pars. 22
(a) and (b) from the health care provider and, if the requirements, if any, under s. 23
632.798 (2) (d) are met, a good faith estimate, from their insurers or self-insured 24
health plans, of the insured's total out-of-pocket cost according to the insured's
benefit terms for the specified health care service in the geographic region in which 2
the health care service will be provided.
(g) The requirements under pars. (a) to (f) do not apply to any of the following: