LRBs0263/2
RLR&PJK:cjs:ph
2009 - 2010 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2009 SENATE BILL 418
February 2, 2010 - Offered by Senator Sullivan.
SB418-SSA1,1,4
1An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 153.21 (title),
2185.981 (4t) and 185.983 (1) (intro.); and
to create 146.903, 153.21 (3), 609.71
3and 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
out-of-pocket cost.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB418-SSA1,3,4
140.51
(8) Every health care coverage plan offered by the state under sub. (6)
2shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
3and (10), 632.747, 632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
4632.87 (3) to (6), 632.885, 632.895 (5m) and (8) to (17), and 632.896.
SB418-SSA1,3,107
40.51
(8m) Every health care coverage plan offered by the group insurance
8board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
9632.748,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885, and 632.895
10(11) to (17).
SB418-SSA1,3,1813
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
14a village provides health care benefits under its home rule power, or if a town
15provides health care benefits, to its officers and employees on a self-insured basis,
16the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
17632.746 (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).
SB418-SSA1,3,2421
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
2249.493 (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).
SB418-SSA1,4,2
1146.903 Disclosures required of health care providers and hospitals. 2(1) Definitions. In this section:
SB418-SSA1,4,33
(a) "Ambulatory surgical center" has the meaning given in
42 CFR 416.2.
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(b) "Clinic" means a place, other than a residence or a hospital, that is used
5primarily for the provision of nursing, medical, podiatric, dental, chiropractic, or
6optometric care and treatment.
SB418-SSA1,4,97
(c) "Health care provider" has the meaning given in s. 146.81 (1) (a) to (L) and
8includes a clinic and an ambulatory surgical center but does not include a nursing
9home, as defined in s. 50.01 (3).
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(d) "Hospital" has the meaning given in s. 50.33 (2).
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(e) "Median billed charge" means one of the following:
SB418-SSA1,4,1812
1. For a health care provider, the amount the health care provider charged,
13before any discount or contractual rate applicable to certain patients or payers was
14applied, during the first 2 calendar quarters of the most recently completed calendar
15year, as calculated by arranging the charges in that reporting period from highest
16to lowest and selecting the middle charge in the sequence or, for an even number of
17charges, selecting the 2 middle charges in the sequence and calculating the average
18of the 2.
SB418-SSA1,4,2419
2. For a hospital, the amount the hospital charged, before any discount or
20contractual rate applicable to certain patients or payers was applied, during the 4
21calendar quarters for which the hospital most recently reported data under ch. 153,
22as calculated by arranging the charges in the reporting period from highest to lowest
23and selecting the middle charge in the sequence or, for an even number of charges,
24selecting the 2 middle charges in the sequence and calculating the average of the 2.
SB418-SSA1,5,2
1(f) "Medicare" means coverage under part A or part B of Title XVIII of the
2federal Social Security Act,
42 USC 1395 to
1395dd.
SB418-SSA1,5,3
3(2) Department duties. (a) The department shall do all of the following:
SB418-SSA1,5,44
1. Categorize health care providers by type.
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2. For each type of health care provider, annually identify the 25 presenting
6conditions for which that type of health care provider most frequently provides
7health care services.
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3. Prescribe the methods by which health care providers shall calculate and
9present median billed charges and Medicare and private 3rd-party payer payments
10under sub. (3) (b).
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(b) In performing the duties under par. (a), the department shall consult with
12organizations in this state that do all of the following:
SB418-SSA1,5,1413
1. Develop performance measures for assessing the quality of health care
14services.
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2. Guide the collection, validation, and analysis of data related to measures
16described under subd. 1.
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3. Report results of assessments of the quality of health care services.
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4. Share best practices of organizations that provide health care services.
SB418-SSA1,5,24
19(3) Health care provider disclosure of charges. (a) Except as provided in
20par. (g), a health care provider or the health care provider's designee shall, upon
21request by and at no cost to a health care consumer, disclose to the consumer within
22a reasonable period of time after the request, the median billed charge, assuming no
23medical complications, for a health care service, diagnostic test, or procedure that is
24specified by the consumer and that is provided by the health care provider.
SB418-SSA1,6,4
1(b) Except as provided in par. (g), a health care provider shall prepare a single
2document that lists the following charge information, assuming no medical
3complications, for diagnosing and treating each of the 25 presenting conditions
4identified for the health care provider's provider type under sub. (2):
SB418-SSA1,6,55
1. The median billed charge.
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2. If the health care provider is certified as a provider of Medicare, the Medicare
7payment to the provider.
SB418-SSA1,6,88
3. The average allowable payment from private, 3rd-party payers.
SB418-SSA1,6,119
(c) Except as provided in par. (g), a health care provider or the health care
10provider's designee shall, upon request by and at no cost to a health care consumer,
11provide the consumer a copy of the document prepared under par. (b).
SB418-SSA1,6,1312
(d) Except as provided in par. (g), a health care provider shall annually update
13the document under par. (b).
SB418-SSA1,6,1714
(e) Information provided upon request under par. (a) or included on the
15document under par. (b) does not constitute a legally binding estimate of the charge
16for a specific patient or the amount that a 3rd-party payer will pay on behalf of the
17patient.
SB418-SSA1,7,218
(f) Except as provided in par. (g), a health care provider shall prominently
19display, in the area of the health care provider's practice or facility that is most
20commonly frequented by health care consumers, a statement informing the
21consumers 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.
23632.798 (2) (d) are met, a good faith estimate, from their insurers or self-insured
24health plans, of the insured's total out-of-pocket cost according to the insured's
1benefit terms for the specified health care service in the geographic region in which
2the health care service will be provided.
SB418-SSA1,7,33
(g) The requirements under pars. (a) to (f) do not apply to any of the following:
SB418-SSA1,7,54
1. A health care provider that practices individually or in association with not
5more than 2 other individual health care providers.
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2. A health care provider that is an association of 3 or fewer individual health
7care providers.
SB418-SSA1,7,12
8(4) H
ospital disclosure of charges. (a) Each hospital shall prepare a single
9document that lists the following charge information, assuming no medical
10complications, for inpatient care for each of the 75 diagnosis related groups identified
11under s. 153.21 (3) and the following charge information for each of the 75 outpatient
12surgical procedures identified under s. 153.21 (3):
SB418-SSA1,7,1313
1. The median billed charge.
SB418-SSA1,7,1414
2. The average allowable payment under Medicare.
SB418-SSA1,7,1515
3. The average allowable payment from private, 3rd-party payers.
SB418-SSA1,7,1716
(b) A hospital shall, upon request by and at no cost to a health care consumer,
17provide the consumer a copy of the document prepared under par. (a).
SB418-SSA1,7,1818
(c) A hospital shall update the document under par. (a) every calendar quarter.
SB418-SSA1,7,2119
(d) Information included on the document under par. (a) does not constitute a
20legally binding estimate of the charge for a specific patient or the amount that a
213rd-party payer will pay on behalf of the patient.
SB418-SSA1,8,422
(e) Each hospital shall prominently display, in the area of the hospital that is
23most commonly frequented by health care consumers, a statement informing the
24consumers that they have the right to receive a copy of the document under par. (a)
25from the hospital and, if the requirements, if any, under s. 632.798 (2) (d) are met,
1a good faith estimate, from their insurers or self-insured health plans, of the
2insured's total out-of-pocket cost according to the insured's benefit terms for the
3specified health care service in the geographic region in which the health care service
4will be provided.
SB418-SSA1,8,6
5(5) Penalty. (a) Whoever violates sub. (3) or (4) may be required to forfeit not
6more than $250 for each violation.
SB418-SSA1,8,127
(b) The department may directly assess forfeitures provided for under par. (a).
8If the department determines that a forfeiture should be assessed for a particular
9violation, the department shall send a notice of assessment to the alleged violator.
10The notice shall specify the amount of the forfeiture assessed, the violation, and the
11statute or rule alleged to have been violated, and shall inform the alleged violator of
12the right to a hearing under par. (c).
SB418-SSA1,8,2413
(c) An alleged violator may contest an assessment of a forfeiture by sending,
14within 10 days after receipt of notice under par. (b), a written request for a hearing
15under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1).
16The administrator of the division may designate a hearing examiner to preside over
17the case and recommend a decision to the administrator under s. 227.46. The
18decision of the administrator of the division shall be the final administrative
19decision. The division shall commence the hearing within 30 days after receipt of the
20request for a hearing and shall issue a final decision within 15 days after the close
21of the hearing. Proceedings before the division are governed by ch. 227. In any
22petition for judicial review of a decision by the division, the party, other than the
23petitioner, who was in the proceeding before the division shall be the named
24respondent.
SB418-SSA1,9,6
1(d) All forfeitures shall be paid to the department within 10 days after receipt
2of notice of assessment or, if the forfeiture is contested under par. (c), within 10 days
3after receipt of the final decision after exhaustion of administrative review, unless
4the final decision is appealed and the order is stayed by court order. The department
5shall remit all forfeitures paid to the secretary of administration for deposit in the
6school fund.
SB418-SSA1,9,107
(e) The attorney general may bring an action in the name of the state to collect
8any forfeiture imposed under this subsection if the forfeiture has not been paid
9following the exhaustion of all administrative and judicial reviews. The only issue
10to be contested in any such action is whether the forfeiture has been paid.
SB418-SSA1, s. 6
11Section
6. 153.21 (title) of the statutes is amended to read: