LRB-0920/2
RLR&PJK:wlj:md
2009 - 2010 LEGISLATURE
October 29, 2009 - Introduced by Representatives Vukmir, Kramer, Tauchen,
Kerkman, Townsend, Davis, Strachota, Knodl, Murtha, Ripp, Gunderson,
Vos, Bies, LeMahieu, Petrowski, Honadel, Nass, Nygren, Van Roy, M.
Williams, Suder, J. Ott, Pridemore, Kleefisch, Rhoades, Zipperer, Brooks,
Petersen, Lothian, Spanbauer, Huebsch, Newcomer, Montgomery, Nerison,
A. Ott, Stone and
Kestell, cosponsored by Senators Kanavas, Darling,
Hopper, A. Lasee, Schultz and Grothman. Referred to Committee on Health
and Healthcare Reform.
AB539,1,6
1An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.981 (4t)
2and 185.983 (1) (intro.); and
to create 146.903, 609.71 and 632.798 of the
3statutes;
relating to: disclosure of information by health care providers,
4insurers, and governmental self-insured plans; requiring acceptance by a
5health care provider of a payment amount in certain circumstances; and
6requiring the exercise of rule-making authority.
Analysis by the Legislative Reference Bureau
Under current law, if an applicant for Medical Assistance (MA) is determined
to be eligible for MA retroactively (for three months) and a provider bills the
applicant directly for services and benefits rendered during the retroactive period,
the provider must submit MA claims for those services and benefits that are covered
under MA. Upon receiving MA payment under the claims, the provider must
reimburse the MA recipient, or other person who made the prior payment on behalf
of the recipient, the amount of the prior payment made for services provided to the
recipient during the retroactive eligibility period.
This bill restricts payment that a "health care provider," as defined in the bill,
may accept from certain patients who are uninsured or who do not have "public
coverage," as defined in the bill. If the patient, within 90 days after receiving a health
care service, diagnostic test, or procedure or the first treatment or visit of a course
of treatment as part of a health care service, obtains coverage from an insurer or a
self-insured health plan under a contract for not less than one year, the health care
provider must accept, as payment from the patient for the service, test, or procedure
no more than the insurer's or plan's payment amount for that service, test, or
procedure, or, if the service or provider is not covered under the coverage the patient
obtains, no more than the average rate paid by insurers or self-insured health plans
for the service, test, or procedure. However, the patient may be liable to the health
care provider for out-of-pocket costs, finance charges, and collection costs incurred
that would not have been covered under the patient's coverage. The insurer or
self-insured health plan that provides coverage must provide to the patient a dollar
estimate of the applicable payment amount for the service, test, or procedure the
patient received. A health care provider must provide to a patient who is uninsured
or does not have public coverage, at the time the health care service, test, or
procedure is provided or after the first treatment or visit of a course of treatment,
information about this restriction on payment and information about the restriction
on acceptance of patient payment for MA applicants who receive retroactive
eligibility.
Under the bill, if a patient is recommended, referred for service, or prescribed
a health care service (including any applicable course of treatment), diagnostic test,
or procedure for which the charge exceeds $500 or any higher amount that the
Department of Health Services (DHS) promulgates by rule (the minimum cost), the
health care provider must provide an estimate of the charge to the patient, whether
insured or uninsured, or the patient's agent who requests it. The estimate of the
charge must be provided at the time of scheduling of the health care service,
diagnostic test, procedure, or course of treatment, or within ten business days of the
request, whichever is later. The bill specifies numerous requirements for the
estimate of charge, except that, in lieu of several of the requirements, a health care
provider may provide to the patient or his or her agent an estimate of charge that is
a single fixed-price estimate of the total cost of the health care service, diagnostic
test, or procedure.
The bill requires DHS, by rule, biennially to adjust the dollar amount that is
specified for minimum cost and specifies a procedure, using the consumer price
index, by which the adjusted dollar amount must be calculated. DHS may
promulgate the amount as an emergency rule without providing a finding of
emergency or complying with certain other standards for promulgating emergency
rules.
The bill requires a self-insured health plan of the state or a county, city, village,
town, or school district, or an insurer that provides health care coverage under a
health care plan, including a defined network plan or a sickness care plan operated
by a cooperative association, to provide to an insured under the health care plan or
an enrollee under the self-insured health plan, any of the following if requested by
the insured or enrollee: 1) a description of the coverage, including benefits and
cost-sharing requirements, under the health care plan or self-insured health plan;
2) a description of any pre-certification or other requirements that an insured or
enrollee must complete before any care is approved by the insurer or self-insured
health plan; and 3) a summary of the insured's or enrollee's coverage with respect to
a specific medical service or course of treatment. The summary of coverage is based
on information relating to an estimate of a charge for a medical service or course of
treatment that was provided by a provider or group of providers to the insured or
enrollee and must include an estimate of the total out-of-pocket costs that the
insured or enrollee may incur, an estimate of the amount that the insurer or
self-insured health plan has paid to the provider or providers, any limits on what the
insurer or self-insured health plan will pay if the service or course of treatment is
received from a nonparticipating or out-of-network provider, and any discounts that
the insurer or self-insured health plan is willing to offer the insured or enrollee if the
service or course of treatment is received from a different provider.
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:
AB539, s. 1
1Section
1. 40.51 (8) of the statutes is amended to read:
AB539,3,52
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,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
5632.87 (3) to
(5) (6), 632.895 (5m) and (8) to (15), and 632.896.
AB539, s. 2
6Section
2. 40.51 (8m) of the statutes is amended to read:
AB539,3,97
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,
632.798, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to (15).
AB539, s. 3
10Section
3. 66.0137 (4) of the statutes is amended to read:
AB539,4,211
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),
1632.746 (10) (a) 2. and (b) 2., 632.747 (3),
632.798, 632.85, 632.853, 632.855, 632.87
2(4),
and (5)
, and (6), 632.895 (9) to (15), 632.896, and
767.25 (4m) (d) 767.513 (4).
AB539, s. 4
3Section
4. 120.13 (2) (g) of the statutes is amended to read:
AB539,4,74
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),
6632.798, 632.85, 632.853, 632.855, 632.87 (4)
and, (5)
, and (6), 632.895 (9) to (15),
7632.896, and
767.25 (4m) (d) 767.513 (4).
AB539, s. 5
8Section
5. 146.903 of the statutes is created to read:
AB539,4,10
9146.903 Disclosures required of health care providers. (1) In this
10section:
AB539,4,1111
(a) "Ambulatory surgical center" has the meaning given in
42 CFR 416.2.
AB539,4,1412
(b) "Average paid rate" means the average amount that a health care provider
13currently accepts as payment in full for a health care service, diagnostic test, or
14procedure, after any discount applicable to certain patients is applied.
AB539,4,1715
(c) "Charged rate" means the average, median, or actual amount that is
16currently charged by a health care provider to a patient for a health care service,
17diagnostic test, or procedure.
AB539,4,2018
(d) "Clinic" means a place, other than a residence, that is used primarily for the
19provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and
20treatment.
AB539,4,2421
(e) "Course of treatment" means, as part of a health care service, the
22management and care, including related therapy and rehabilitation, of a patient
23over time for the purpose of combating disease or disorder or temporarily or
24permanently relieving symptoms.
AB539,4,2525
(f) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
AB539,5,2
1(g) "Health care provider" has the meaning given in s. 146.81 (1) and includes
2a clinic and an ambulatory surgical center.
AB539,5,53
(h) "Health care service, diagnostic test, or procedure" includes physical
4therapy, speech therapy, occupational therapy, chiropractic treatment, or mental
5therapy, but does not include a prescription drug.
AB539,5,76
(i) "Insured" means covered under a health care plan offered by an insurer or
7under a self-insured health plan.
AB539,5,158
(j) "Insurer" means an insurer that is authorized to do business in this state,
9in one or more lines of insurance that includes health insurance, and that provides
10coverage, excluding public coverage, of health care expenses under health care plans
11covering individuals or groups in this state. The term includes a health maintenance
12organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s.
13609.01 (4), an insurer operating as a cooperative association organized under ss.
14185.981 to 185.985, and a limited service health organization, as defined in s. 609.01
15(3).
AB539,5,1616
(k) "Medical Assistance" means aid provided under subch. IV of ch. 49.
AB539,5,1817
(L) "Medicare" means coverage under Part A or Part B of Title XVIII of the
18federal Social Security Act,
42 USC 1395 to
1395hhh.
AB539,5,2019
(m) "Mental therapy" includes services and treatment for mental illness,
20developmental disability, alcohol and other drug abuse, and drug dependence.
AB539,5,2221
(n) "Minimum cost" means $500 or any higher amount that is specified by the
22department by rule.
AB539,6,223
(p) "Patient's agent" means the parent, guardian, or legal custodian of a minor
24patient; the spouse of a patient; an agent of a patient under a valid power of attorney
1for health care; a guardian of the person, as defined in s. 54.01 (12) of a patient; or
2any individual who is authorized by the patient to act as his or her agent.
AB539,6,33
(q) "Prescription drug" has the meaning given in s. 450.01 (20).
AB539,6,94
(r) "Public coverage" means coverage for health care expenses that is funded
5in whole or in part under any state-assisted or federally assisted program, including
6Medical Assistance and Medicare, for which the average reimbursement rate for a
7health care service, diagnostic test, or procedure is lower than an insurer's or
8self-insured health plan's average paid rate for the identical service, test, or
9procedure.
AB539,6,1010
(s) "Self-insured health plan" has the meaning given in s. 632.745 (24).
AB539,6,18
11(2) (a) If a patient is not insured or does not have public coverage at the time
12he or she first receives a particular health care service, diagnostic test, or procedure
13or the first treatment or visit of a course of treatment and, within 90 days after
14receipt of the service, test, procedure, or treatment, obtains from an insurer or a
15self-insured health plan coverage that is under a contract for not less than one year,
16the health care provider shall accept, as payment from the patient for the service,
17test, procedure, or treatment provided to the patient, whichever of the following is
18applicable:
AB539,6,2219
1. If the health care provider and the service, test, procedure, or treatment are
20covered under the health care coverage that the patient obtains, an amount that is
21no more than the insurer's or plan's payment amount for that service, test, or
22procedure.
AB539,7,223
2. If the health care provider or the service, test, procedure, or treatment is not
24covered under the health care coverage that the patient obtains, an amount that is
1no more than the average rate paid by insurers or self-insured health plans for the
2service, test, procedure, or treatment.
AB539,7,53
(b) A patient under par. (a) may be liable to the health care provider for any
4out-of-pocket costs, finance charges, and collection costs incurred that would not
5have been covered under the patient's coverage.
AB539,7,106
(c) The health care provider of a patient who is not insured or who does not have
7public coverage at the time that a health care service, diagnostic test, or procedure
8is provided or after the first treatments or visit of a course of treatment shall inform
9the patient of the requirements under par. (a) and of the provider's reimbursement
10requirement for a recipient of Medical Assistance under s. 49.49 (3m) (a) 2.
AB539,7,1411
(d) The insurer or self-insured health plan that provides coverage specified
12under par. (a) shall provide to the patient a dollar estimate of the insurer's or plan's
13applicable payment amount for the health care service, diagnostic test, procedure,
14or treatment received by the patient, as specified under par. (a).
AB539,7,21
15(3) (a) If a patient who is insured or is not insured is recommended to, referred
16to, or is under the care of a health care provider or group of health care providers for
17a health care service, including any applicable course of treatment, or diagnostic test
18or procedure for which the charge exceeds the minimum cost, and if the patient or
19the patient's agent requests an estimate of the charge, the health care provider or
20group of health care providers, if applicable, shall provide the patient or the patient's
21agent with an estimate of the charge.
AB539,8,222
(b) Except as provided in par. (c) 2., for an estimate of the charge that is
23provided under par. (a), the health care provider or group of health care providers,
24if applicable, shall provide the following, as applicable, at the time of scheduling of
1the health care service, diagnostic test, or procedure or course of treatment or within
210 business days of the request, whichever is later:
AB539,8,43
1. For an inpatient surgical procedure and course of treatment, an estimate of
4the charge that shall include all of the following:
AB539,8,75
a. The reasonably anticipated services of health care providers who will likely
6provide health care services, during and after the surgical procedure and during any
7related course of treatment.
AB539,8,98
b. The reasonably anticipated total charge for hospitalization, daily charge for
9hospitalization, and number of days of hospital stay.
AB539,8,1110
2. For an outpatient surgical procedure and course of treatment, an estimate
11of the charge that shall include the reasonably anticipated total charge.