LRB-0992/1
PJK:jld:jf
2009 - 2010 LEGISLATURE
June 29, 2009 - Introduced by Representatives Townsend, Berceau, Nerison,
Richards, Soletski and
Turner, cosponsored by Senators Hansen, Taylor and
Wirch. Referred to Committee on Insurance.
AB331,1,4
1An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 111.91 (2) (n), 120.13 (2) (g),
2185.981 (4t), 185.983 (1) (intro.), 609.22 (1) and 609.22 (2); and
to create
3609.835 and 632.895 (16) of the statutes;
relating to: insurance coverage of
4orthotic and prosthetic devices and services.
Analysis by the Legislative Reference Bureau
This bill requires a health care plan that covers hospital, medical, or surgical
expenses to cover the cost of orthotic devices and prosthetic devices that are
prescribed by a physician as medically necessary. Orthotic devices are defined under
the bill, generally, as rigid or semirigid devices that are used to support, restrain,
limit, correct, or enhance motion in a weak or deformed human body part. Prosthetic
devices are defined as replacements for an external human body part in whole or in
part. Besides covering the devices, a health care plan must cover services and
supplies relating to the devices and the repair or replacement of the devices.
Additionally, a defined network plan must ensure that covered orthotic and
prosthetic services may be obtained from at least two different providers of orthotic
devices and at least two different providers of prosthetic devices that are located
within a reasonable travel distance or time, defined as 60 miles or less or 60 minutes
or less. If a defined network plan does not have at least two different providers of
orthotic devices and at least two different providers of prosthetic devices in its
provider network, it must cover the services of a provider outside its network that
is located within a reasonable travel distance or time, at no additional cost to an
insured under the plan, to ensure that insureds under the plan have a choice of at
least two different providers of orthotic devices and at least two different providers
of prosthetic devices.
The coverage requirement applies to both individual and group health
insurance policies and plans, including health care plans offered by the state, a
municipality, or a school district. The coverage may not be subject to any limitations,
exclusions, or cost-sharing provisions that are greater than those that apply
generally under the policy or plan.
For further information see the state and local fiscal estimate, which will be
printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB331, s. 1
1Section
1. 40.51 (8) of the statutes is amended to read:
AB331,2,52
40.51
(8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
4and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to
5(5) (6), 632.895 (5m) and (8) to
(15) (16), and 632.896.
AB331, s. 2
6Section
2. 40.51 (8m) of the statutes is amended to read:
AB331,2,97
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, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to
(15) (16).
AB331, s. 3
10Section
3. 66.0137 (4) of the statutes is amended to read:
AB331,2,1611
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
12a village provides health care benefits under its home rule power, or if a town
13provides health care benefits, to its officers and employees on a self-insured basis,
14the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
15632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.85, 632.853, 632.855, 632.87 (4),
and 16(5)
, and (6), 632.895 (9) to
(15)
(16), 632.896, and
767.25 (4m) (d) 767.513 (4).
AB331, s. 4
17Section
4. 111.91 (2) (n) of the statutes is amended to read:
AB331,3,2
1111.91
(2) (n) The provision to employees of the health insurance coverage
2required under s. 632.895 (11) to (14)
and (16).
AB331, s. 5
3Section
5. 120.13 (2) (g) of the statutes is amended to read:
AB331,3,74
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
549.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
6632.85, 632.853, 632.855, 632.87 (4)
and, (5)
, and (6), 632.895 (9) to
(15)
(16), 632.896,
7and
767.25 (4m) (d) 767.513 (4).
AB331, s. 6
8Section
6. 185.981 (4t) of the statutes is amended to read:
AB331,3,129
185.981
(4t) A sickness care plan operated by a cooperative association is
10subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.85,
11632.853, 632.855, 632.87 (2m), (3), (4),
and (5)
, and (6), 632.895 (10) to
(15) (16), and
12632.897 (10) and chs. 149 and 155.
AB331, s. 7
13Section
7. 185.983 (1) (intro.) of the statutes is amended to read:
AB331,3,2014
185.983
(1) (intro.) Every such voluntary nonprofit sickness care plan shall be
15exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
16601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
17631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.85, 632.853,
18632.855, 632.87 (2m), (3), (4),
and (5)
, and (6), 632.895 (5) and (9) to
(15) (16), 632.896,
19and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring association
20shall:
AB331, s. 8
21Section
8. 609.22 (1) of the statutes is amended to read:
AB331,4,222
609.22
(1) Providers. A Subject to s. 632.895 (16) (c) 1. and 2., a defined
23network plan shall include a sufficient number, and sufficient types, of qualified
24providers to meet the anticipated needs of its enrollees, with respect to covered
1benefits, as appropriate to the type of plan and consistent with normal practices and
2standards in the geographic area.
AB331, s. 9
3Section
9. 609.22 (2) of the statutes is amended to read:
AB331,4,74
609.22
(2) Adequate choice. A defined network plan that is not a preferred
5provider plan shall ensure that, with respect to covered benefits, each enrollee has
6adequate choice among participating providers and that the providers are accessible
,
7subject to s. 632.895 (16) (c) 1. and 3., and qualified.
AB331, s. 10
8Section
10. 609.835 of the statutes is created to read:
AB331,4,10
9609.835 Coverage of orthotic and prosthetic devices and services. 10Defined network plans are subject to s. 632.895 (16).
AB331, s. 11
11Section
11. 632.895 (16) of the statutes is created to read:
AB331,4,1312
632.895
(16) Coverage of orthotic and prosthetic devices and services. (a)
13In this subsection:
AB331,4,1414
1. "Defined network plan" has the meaning given in s. 609.01 (1b).
AB331,4,1615
2. "Human body part" includes a leg, a foot, an arm, a hand, the torso, the neck,
16and the head.
AB331,4,1917
3. "Orthotic device" means a rigid or semirigid device used to support a weak
18or deformed human body part, or to restrain, limit, correct, or enhance motion in a
19diseased or injured human body part.
AB331,4,2120
4. "Prosthetic device" means a replacement for an external human body part
21that is designed to replace the human body part in whole or in part.
AB331,4,2222
5. "Self-insured health plan" has the meaning given in s. 632.745 (24).
AB331,4,2523
(b) Every disability insurance policy, and every self-insured health plan, that
24provides coverage of hospital, medical, or surgical expenses shall provide coverage
25of all of the following:
AB331,5,2
11. Orthotic devices and prosthetic devices that are prescribed by a physician
2and determined by the prescribing physician to be medically necessary.
AB331,5,73
2. Services and supplies relating to an orthotic or prosthetic device that the
4prescribing physician determines to be medically necessary, including design,
5fabrication, material and component selection, measurements, fittings, static and
6dynamic alignment, device maintenance, and instruction of the wearer of the device
7in the use and care of the device.
AB331,5,98
3. The repair or replacement of an orthotic or prosthetic device that the
9prescribing physician determines to be medically necessary.
AB331,5,1510
(c) 1. A defined network plan that is subject to this subsection shall ensure that
11the services for which coverage is required under par. (b) 2. are available to insureds
12under the defined network plan from at least 2 different providers in this state of
13orthotic devices and at least 2 different providers in this state of prosthetic devices
14that are located within a reasonable travel distance or time and whose services are
15covered under the plan.
AB331,5,2416
2. If the provider network of the defined network plan does not include at least
172 different providers of orthotic devices and at least 2 different providers of prosthetic
18devices that are located within a reasonable travel distance or time for any insured,
19the defined network plan shall cover the services of providers of orthotic or prosthetic
20devices that are not in the plan's network to ensure that insureds under the plan have
21a choice of at least 2 different providers of orthotic devices and at least 2 different
22providers of prosthetic devices that are located within a reasonable travel distance
23or time, and may not require an insured to pay more than what the insured would
24have paid had the provider been in the plan's network.
AB331,6,3
13. For purposes of subds. 1. and 2., a reasonable travel distance for any insured
2shall be 60 miles or less and a reasonable travel time for any insured shall be 60
3minutes or less.
AB331,6,84
4. A defined network plan under subd. 2. must include information in policies
5or certificates provided to insureds explaining the circumstances under which, and
6how, an insured may obtain a referral to a provider of orthotic or prosthetic devices
7that is not in the plan's network and must provide such information to an insured
8upon request.
AB331,6,129
(d) The coverage required under this subsection may not be subject to
10limitations, exclusions, or cost-sharing provisions that are greater than those that
11apply generally to services or items under the disability insurance policy or
12self-insured health plan.
AB331,6,1414
(1) This act first applies to all of the following:
AB331,6,1815
(a) Except as provided in paragraphs (b) and (c
), disability insurance policies
16that are issued or renewed, and self-insured governmental or school district health
17plans that are established, extended, modified, or renewed, on the effective date of
18this paragraph.
AB331,6,2119
(b) Disability insurance policies covering employees who are affected by a
20collective bargaining agreement containing provisions inconsistent with this act
21that are issued or renewed on the earlier of the following: