LRB-3406/2
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2009 - 2010 LEGISLATURE
October 21, 2009 - Introduced by Representatives Pasch, Richards, Benedict,
Soletski, Smith, Black, Parisi, Milroy, Kaufert, Fields, Pope-Roberts,
Zepnick, Hixson, Roys, Pocan, A. Ott, Berceau, Sinicki, Molepske Jr.,
Grigsby, Young, Turner, Hebl, Sherman, Jorgensen, Toles
and Hilgenberg,
cosponsored by Senators Hansen, Wirch, Taylor, Robson, Lehman, Vinehout,
Carpenter, Lassa, Miller, Risser, Erpenbach
and Coggs. Referred to
Committee on Health and Healthcare Reform.
AB512,1,11 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) and 632.89 (5); to renumber and amend 632.89 (2) (a) 1., 632.89
4(2) (c) 1., 632.89 (2) (d) 1., 632.89 (2) (dm) 1. and 632.89 (2) (e); to amend 40.51
5(8), 40.51 (8m), 46.10 (8) (d), 46.10 (14) (a), 49.345 (8) (d), 49.345 (14) (a), 66.0137
6(4), 120.13 (2) (g), 185.981 (4t), 185.983 (1) (intro.), 301.12 (8) (d), 301.12 (14)
7(a), 632.89 (title) and 632.89 (2) (title); to repeal and recreate 632.89 (1) (b),
8632.89 (1) (em) and 632.89 (5) (title); and to create 111.91 (2) (qm), 609.71,
9632.89 (2p), 632.89 (3), 632.89 (3p) and 632.89 (5) (a) (title) of the statutes;
10relating to: health insurance coverage of nervous and mental disorders,
11alcoholism, and other drug abuse problems.
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 bill 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 bill 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. In addition, the bill requires group and
individual health benefit plans and governmental self-insured health plans that
provide coverage for the treatment of mental health and substance abuse problems
and that would cover at least one annual physical examination to cover at least one
annual screening for a covered individual to determine the need for treatment of
mental health and substance abuse problems and for a female covered under the plan
at least one screening during a pregnancy for prepartum depression and at least one
screening within six months after a live birth, stillbirth, or miscarriage for
postpartum depression to determine the need for treatment.
The bill 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 bill 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. In addition, the bill 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.
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:
AB512, s. 1 1Section 1. 40.51 (8) of the statutes, as affected by 2009 Wisconsin Act 28, is
2amended to read:
AB512,3,63 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.
AB512, s. 2 7Section 2. 40.51 (8m) of the statutes, as affected by 2009 Wisconsin Act 28, is
8amended to read:
AB512,3,129 40.51 (8m) Every health care coverage plan offered by the group insurance
10board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
11632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885, 632.89, and 632.895
12(11) to (17).
AB512, s. 3 13Section 3. 46.10 (8) (d) of the statutes is amended to read:
AB512,4,214 46.10 (8) (d) After due regard to the case and to a spouse and minor children
15who are lawfully dependent on the property for support, compromise or waive any
16portion of any claim of the state or county for which a person specified under sub. (2)

1is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or
2by any other 3rd party.
AB512, s. 4 3Section 4. 46.10 (14) (a) of the statutes is amended to read:
AB512,4,184 46.10 (14) (a) Except as provided in pars. (b) and (c), liability of a person
5specified in sub. (2) or s. 46.03 (18) for inpatient care and maintenance of persons
6under 18 years of age at community mental health centers, a county mental health
7complex under s. 51.08, the centers for the developmentally disabled, the Mendota
8Mental Health Institute, and the Winnebago Mental Health Institute or care and
9maintenance of persons under 18 years of age in residential, nonmedical facilities
10such as group homes, foster homes, treatment foster homes, subsidized
11guardianship homes, residential care centers for children and youth, and juvenile
12correctional institutions is determined in accordance with the cost-based fee
13established under s. 46.03 (18). The department shall bill the liable person up to any
14amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by other
153rd-party benefits, subject to rules that include formulas governing ability to pay
16promulgated by the department under s. 46.03 (18). Any liability of the patient not
17payable by any other person terminates when the patient reaches age 18, unless the
18liable person has prevented payment by any act or omission.
AB512, s. 5 19Section 5. 49.345 (8) (d) of the statutes is amended to read:
AB512,4,2420 49.345 (8) (d) After due regard to the case and to a spouse and minor children
21who are lawfully dependent on the property for support, compromise or waive any
22portion of any claim of the state or county for which a person specified under sub. (2)
23is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or
24by any other 3rd party.
AB512, s. 6 25Section 6. 49.345 (14) (a) of the statutes is amended to read:
AB512,5,11
149.345 (14) (a) Except as provided in pars. (b) and (c), liability of a person
2specified in sub. (2) or s. 49.32 (1) for care and maintenance of persons under 18 years
3of age in residential, nonmedical facilities such as group homes, foster homes,
4treatment foster homes, subsidized guardianship homes, and residential care
5centers for children and youth is determined in accordance with the cost-based fee
6established under s. 49.32 (1). The department shall bill the liable person up to any
7amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by other
83rd-party benefits, subject to rules that include formulas governing ability to pay
9established by the department under s. 49.32 (1). Any liability of the person not
10payable by any other person terminates when the person reaches age 18, unless the
11liable person has prevented payment by any act or omission.
AB512, s. 7 12Section 7. 66.0137 (4) of the statutes, as affected by 2009 Wisconsin Act 28,
13is amended to read:
AB512,5,1914 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or
15a village provides health care benefits under its home rule power, or if a town
16provides health care benefits, to its officers and employees on a self-insured basis,
17the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
18632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.85, 632.853, 632.855, 632.87 (4), (5),
19and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
AB512, s. 8 20Section 8. 111.91 (2) (qm) of the statutes is created to read:
AB512,5,2321 111.91 (2) (qm) The requirements under s. 632.89 relating to coverage of
22screening and treatment for nervous and mental disorders and alcoholism and other
23drug problems.
AB512, s. 9 24Section 9. 120.13 (2) (g) of the statutes, as affected by 2009 Wisconsin Act 28,
25is amended to read:
AB512,6,4
1120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
249.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
3632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17),
4632.896, and 767.513 (4).
AB512, s. 10 5Section 10. 185.981 (4t) of the statutes, as affected by 2009 Wisconsin Act 28,
6is amended to read:
AB512,6,107 185.981 (4t) A sickness care plan operated by a cooperative association is
8subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.85,
9632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (10) to
10(17), and 632.897 (10) and chs. 149 and 155.
AB512, s. 11 11Section 11. 185.983 (1) (intro.) of the statutes, as affected by 2009 Wisconsin
12Act 28
, is amended to read:
AB512,6,1913 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be
14exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
15601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
16631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.85, 632.853,
17632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5) and (9) to (17),
18632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring
19association shall:
AB512, s. 12 20Section 12. 301.12 (8) (d) of the statutes is amended to read:
AB512,6,2521 301.12 (8) (d) After due regard to the case and to a spouse and minor children
22who are lawfully dependent on the property for support, compromise or waive any
23portion of any claim of the state or county for which a person specified under sub. (2)
24is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or
25by any other 3rd party.
AB512, s. 13
1Section 13. 301.12 (14) (a) of the statutes is amended to read:
AB512,7,122 301.12 (14) (a) Except as provided in pars. (b) and (c), liability of a person
3specified in sub. (2) or s. 301.03 (18) for care and maintenance of persons under 17
4years of age in residential, nonmedical facilities such as group homes, foster homes,
5treatment foster homes, residential care centers for children and youth and juvenile
6correctional institutions is determined in accordance with the cost-based fee
7established under s. 301.03 (18). The department shall bill the liable person up to
8any amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by
9other 3rd-party benefits, subject to rules which include formulas governing ability
10to pay promulgated by the department under s. 301.03 (18). Any liability of the
11resident not payable by any other person terminates when the resident reaches age
1217, unless the liable person has prevented payment by any act or omission.
AB512, s. 14 13Section 14. 609.71 of the statutes is created to read:
AB512,7,15 14609.71 Coverage of alcoholism and other diseases. Defined network
15plans are subject to s. 632.89.
AB512, s. 15 16Section 15. 632.89 (title) of the statutes is amended to read:
AB512,7,18 17632.89 (title) Required coverage of Coverage of mental disorders,
18alcoholism, and other diseases.
AB512, s. 16 19Section 16. 632.89 (1) (b) of the statutes is repealed and recreated to read:
AB512,7,2020 632.89 (1) (b) "Health benefit plan" has the meaning given in s. 632.745 (11).
AB512, s. 17 21Section 17. 632.89 (1) (em) of the statutes is repealed and recreated to read:.
AB512,7,2322 632.89 (1) (em) "Self-insured health plan" has the meaning given in s. 632.745
23(24).
AB512, s. 18 24Section 18. 632.89 (2) (title) of the statutes is amended to read:
AB512,7,2525 632.89 (2) (title) Required coverage for group plans.
AB512, s. 19
1Section 19. 632.89 (2) (a) 1. of the statutes is renumbered 632.89 (2) (a) and
2amended to read:
AB512,8,73 632.89 (2) (a) Conditions covered. A group or blanket disability insurance
4policy issued by an insurer
health benefit plan and a self-insured health plan shall
5provide coverage of nervous and mental disorders and alcoholism and other drug
6abuse problems if required by pars. (c) to (dm) and as provided in pars. (b) (c) to (e)
7(dm) and subs. (2p) and (3).
AB512, s. 20 8Section 20. 632.89 (2) (a) 2. of the statutes is repealed.
AB512, s. 21 9Section 21. 632.89 (2) (b) of the statutes is repealed.
AB512, s. 22 10Section 22. 632.89 (2) (c) 1. of the statutes is renumbered 632.89 (2) (c) and
11amended to read:
AB512,8,1612 632.89 (2) (c) Minimum coverage Coverage of inpatient hospital services. If a
13group or blanket disability insurance policy issued by an insurer health benefit plan
14or a self-insured health plan
provides coverage of any inpatient hospital treatment,
15the policy plan shall provide coverage for inpatient hospital services for the
16treatment of conditions under par. (a) 1. as provided in subd. 2.
AB512, s. 23 17Section 23. 632.89 (2) (c) 2. of the statutes is repealed.
AB512, s. 24 18Section 24. 632.89 (2) (d) 1. of the statutes is renumbered 632.89 (2) (d) and
19amended to read:
AB512,8,2420 632.89 (2) (d) Minimum coverage Coverage of outpatient services. If a group or
21blanket disability insurance policy issued by an insurer
health benefit plan or a
22self-insured health plan
provides coverage of any outpatient treatment, the policy
23plan shall provide coverage for outpatient services for the treatment of conditions
24under par. (a) 1. as provided in subd. 2.
AB512, s. 25 25Section 25. 632.89 (2) (d) 2. of the statutes is repealed.
AB512, s. 26
1Section 26. 632.89 (2) (dm) 1. of the statutes is renumbered 632.89 (2) (dm)
2and amended to read:
AB512,9,83 632.89 (2) (dm) Minimum coverage Coverage of transitional treatment
4arrangements.
If a group or blanket disability insurance policy issued by an insurer
5health benefit plan or a self-insured health plan provides coverage of any inpatient
6hospital treatment or any outpatient treatment, the policy plan shall provide
7coverage for transitional treatment arrangements for the treatment of conditions
8under par. (a) 1. as provided in subd. 2.
AB512, s. 27 9Section 27. 632.89 (2) (dm) 2. of the statutes is repealed.
AB512, s. 28 10Section 28. 632.89 (2) (e) of the statutes is renumbered 632.89 (5) (b) and
11amended to read:
AB512,9,1512 632.89 (5) (b) Exclusion Certain health care plans. This subsection section does
13not apply to a health care plan offered by a limited service health organization, as
14defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4),
15that is not a defined network plan, as defined in s. 609.01 (1b)
.
AB512, s. 29 16Section 29. 632.89 (2m) of the statutes is renumbered 632.89 (4m).
AB512, s. 30 17Section 30. 632.89 (2p) of the statutes is created to read:
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