AB75: Bill Text

AB75,1548,6 1. A different but comparable individual major medical or comprehensive health benefit plan currently offered by the insurer.

AB75,1548,8 2. An individual major medical or comprehensive health benefit plan currently offered by the insurer with more limited benefits.

AB75,1548,10 3. An individual major medical or comprehensive health benefit plan currently offered by the insurer with higher deductibles.

AB75,1548,13 (b) Modify his or her existing coverage by electing an optional higher deductible, if any, under the individual major medical or comprehensive health benefit plan.

AB75,1548,17 (3) (a) The insurer may not impose any new preexisting condition exclusion under the new or modified coverage under sub. (2) that did not apply to the insured's original coverage and shall allow the insured credit under the new or modified coverage for the period of original coverage.

AB75,1548,20 (b) For the new or modified coverage, the insurer may not rate for health status other than on the insured's health status at the time the insured applied for the original coverage and as the insured disclosed on the original application.

AB75,1548,23 (4) (a) Annually, the insurer shall mail to each insured under an individual major medical or comprehensive health benefit plan issued by the insurer, a notice that includes all of the following information:

AB75,1548,25 1. That the insured has the right to elect alternative coverage as described in sub. (2).

AB75,1549,1 2. A description of the alternatives available to the insured.

AB75,1549,2 3. The procedure for making the election.

AB75,1549,4 (b) The insurer shall mail the notice under par. (a) not more than 3 months nor less than 60 days before the renewal date of the insured's plan.

AB75,1549,7 (5) (a) Nothing in this section requires an insurer to issue alternative coverage under sub. (2) if the insured's coverage may be nonrenewed or discontinued under s. 632.7495 (2), (3) (b), or (4).

AB75,1549,11 (b) Notwithstanding s. 600.01 (1) (b) 3. and 4., this section applies to a group health benefit plan described in s. 600.01 (1) (b) 3. or 4. if that group health benefit plan is an individual major medical or comprehensive health benefit plan as defined in sub. (1).

AB75, s. 3175 Section 3175. 632.76 (2) (a) of the statutes is amended to read:

AB75,1549,18 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years 12 months from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746.

AB75, s. 3176 Section 3176. 632.76 (2) (ac) of the statutes is created to read:

AB75,1549,24 632.76 (2) (ac) An individual disability insurance policy, as defined in s. 632.895 (1) (a), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB75, s. 3177 Section 3177. 632.76 (2) (b) of the statutes is amended to read:

AB75,1550,18 632.76 (2) (b) Notwithstanding par. (a), no claim for loss incurred or disability commencing after 6 months from the date of issue of a medicare supplement policy, medicare replacement policy or long-term care insurance policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage. A Notwithstanding par. (ac), a medicare supplement policy, medicare replacement policy, or long-term care insurance policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Notwithstanding par. (a), if on the basis of information contained in an application for insurance a medicare supplement policy, medicare replacement policy, or long-term care insurance policy excludes from coverage a condition by name or specific description, the exclusion must terminate no later than 6 months after the date of issue of the medicare supplement policy, medicare replacement policy, or long-term care insurance policy. The commissioner may by rule exempt from this paragraph certain classes of medicare supplement policies, medicare replacement policies, and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.

AB75, s. 3178 Section 3178. 632.835 (title) of the statutes is amended to read:

AB75,1550,21 632.835 (title) Independent review of adverse and experimental treatment coverage denial determinations.

AB75, s. 3179 Section 3179. 632.835 (1) (ag) of the statutes is created to read:

AB75,1550,25 632.835 (1) (ag) "Coverage denial determination" means an adverse determination, an experimental treatment determination, a preexisting condition exclusion denial determination, or the rescission of a policy or certificate.

AB75, s. 3180 Section 3180. 632.835 (1) (cm) of the statutes is created to read:

AB75,1551,5 632.835 (1) (cm) "Preexisting condition exclusion denial determination" means a determination by or on behalf of an insurer that issues a health benefit plan denying or terminating treatment or payment for treatment on the basis of a preexisting condition exclusion, as defined in s. 632.745 (23).

AB75, s. 3181 Section 3181. 632.835 (2) (a) of the statutes is amended to read:

AB75,1551,11 632.835 (2) (a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of an adverse determination or an experimental treatment a coverage denial determination made with respect to the insured.

AB75, s. 3182 Section 3182. 632.835 (2) (b) of the statutes is amended to read:

AB75,1551,20 632.835 (2) (b) If an adverse determination or an experimental treatment a coverage denial determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

AB75, s. 3183 Section 3183. 632.835 (2) (bg) 3. of the statutes is amended to read:

AB75,1552,6 632.835 (2) (bg) 3. For any adverse determination or experimental treatment coverage denial determination for which an explanation of benefits is not provided to the insured, the insurer provides a notice that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited, independent review with respect to an urgent matter. The notice shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under subd. 1. The notice shall provide a toll-free telephone number and website, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.

AB75, s. 3184 Section 3184. 632.835 (2) (c) of the statutes is amended to read:

AB75,1552,13 632.835 (2) (c) Except as provided in par. (d), an insured must exhaust the internal grievance procedure under s. 632.83 before the insured may request an independent review under this section. Except as provided in sub. (9) (a), an insured who uses the internal grievance procedure must request an independent review as provided in sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under s. 632.83 (3) (d).

AB75, s. 3185 Section 3185. 632.835 (2) (e) of the statutes is created to read:

AB75,1552,16 632.835 (2) (e) Nothing in this section affects an insured's right to commence a civil proceeding relating to a coverage denial determination.

AB75, s. 3186 Section 3186. 632.835 (3) (a) of the statutes is amended to read:

AB75,1553,5 632.835 (3) (a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the insurer that made or on whose behalf was made the adverse or experimental treatment coverage denial determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. The insured or his or her authorized representative must pay a $25 fee to the independent review organization. If the insured prevails on the review, in whole or in part, the entire amount paid by the insured or his or her authorized representative shall be refunded by the insurer to the insured or his or her authorized representative. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

AB75, s. 3187 Section 3187. 632.835 (3) (e) of the statutes is amended to read:

AB75,1553,17 632.835 (3) (e) In addition to the information under pars. (b) and (c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and pars. (b) and (c). If, on the basis of any additional information, the insurer reconsiders the insured's grievance and determines that the treatment that was the subject of the grievance should be covered, or that the policy or certificate that was rescinded should be reinstated, the independent review is terminated.

AB75, s. 3188 Section 3188. 632.835 (3) (f) of the statutes is renumbered 632.835 (3) (f) 1. and amended to read:

AB75,1554,2 632.835 (3) (f) 1. If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer. A Except as provided in subd. 2., a decision of an independent review organization is binding on the insured and the insurer.

AB75, s. 3189 Section 3189. 632.835 (3) (f) 2. of the statutes is created to read:

AB75,1554,6 632.835 (3) (f) 2. A decision of an independent review organization regarding a preexisting condition exclusion denial determination or a rescission is not binding on the insured.

AB75, s. 3190 Section 3190. 632.835 (3m) (a) of the statutes is amended to read:

AB75,1554,11 632.835 (3m) (a) A decision of an independent review organization regarding an adverse determination or a preexisting condition exclusion denial determination must be consistent with the terms of the health benefit plan under which the adverse determination or preexisting condition exclusion denial determination was made.

AB75, s. 3191 Section 3191. 632.835 (6m) (a) of the statutes is amended to read:

AB75,1554,16 632.835 (6m) (a) Be Unless the review relates to a rescission, be a health care provider who is expert in treating the medical condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through current, actual clinical experience.

AB75, s. 3192 Section 3192. 632.835 (7) (b) of the statutes is amended to read:

AB75,1554,22 632.835 (7) (b) A health benefit plan that is the subject of an independent review and the insurer that issued the health benefit plan shall not be liable to any person for damages attributable to the insurer's or plan's actions taken in compliance with any decision regarding an adverse determination or an experimental treatment determination rendered by a certified independent review organization.

AB75, s. 3193 Section 3193. 632.835 (8) of the statutes is renumbered 632.835 (8) (a) and amended to read:

AB75,1555,9 632.835 (8) (a) Adverse and experimental treatment determinations. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for adverse determinations and experimental treatment determinations and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to adverse determinations and experimental treatment determinations.

AB75, s. 3194 Section 3194. 632.835 (8) (b) of the statutes is created to read:

AB75,1555,19 632.835 (8) (b) Preexisting condition exclusion denials and rescissions. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section for preexisting condition exclusion denial determinations and rescissions and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating with respect to preexisting condition exclusion denial determinations and rescissions.

AB75, s. 3195 Section 3195. 632.835 (9) of the statutes is renumbered 632.835 (9) (a) and amended to read:

AB75,1556,5 632.835 (9) (a) Adverse and experimental treatment determinations. The independent review required under this section with respect to an adverse determination or an experimental treatment determination shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000. Notwithstanding sub. (2) (c), an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000, but before June 15, 2002, with respect to an adverse determination or an experimental treatment determination must request an independent review no later than 4 months after June 15, 2002.

AB75, s. 3196 Section 3196. 632.835 (9) (b) of the statutes is created to read:

AB75,1556,12 632.835 (9) (b) Preexisting condition exclusion denials and rescissions. The independent review required under this section with respect to a preexisting condition exclusion denial determination or a rescission shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after the date stated in the notice published in the Wisconsin Administrative Register by the commissioner under sub. (8) (b).

AB75, s. 3197 Section 3197. 632.845 of the statutes is created to read:

AB75,1556,16 632.845 Prohibiting refusal to cover services because liability policy may cover. (1) In this section, "health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB75,1556,20 (2) An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.

AB75, s. 3198 Section 3198. 632.895 (14m) of the statutes is created to read:

AB75,1556,25 632.895 (14m) Coverage of dependents. (a) Subject to par. (b), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a person as a dependent of an insured shall provide dependent coverage for a child of an insured.

AB75,1557,2 (b) A policy or plan is not required to provide dependent coverage for a child of an insured if any of the following applies:

AB75,1557,3 1. The child is 27 years of age or older.

AB75,1557,4 2. The child is married.

AB75,1557,5 3. The child has other health care coverage.

AB75,1557,7 4. The child is employed full time and his or her employer offers health care coverage to its employees.

AB75,1557,9 5. Coverage of the insured through whom the child has dependent coverage under the policy or plan is discontinued or not renewed.

AB75, s. 3199 Section 3199. Chapter 648 of the statutes is created to read:

AB75,1557,11 CHAPTER 648

AB75,1557,13 Regulation of Care Management Organizations

AB75,1557,14 648.01 Definitions. In this chapter:

AB75,1557,16 (1) "Care management organization" means an entity described in s. 46.284 (3m).

AB75,1557,17 (2) "Department" means the department of health services.

AB75,1557,18 (3) "Enrollee" has the meaning given in s. 46.2805 (3).

AB75,1557,20 (4) "Permittee" means a care management organization issued a permit under this chapter.

AB75,1557,22 648.03 Applicability of other laws. Notwithstanding s. 600.01 (1) (b) 10. a., ss. 600.01, 600.02, 600.03, and 600.12 apply to this chapter.

AB75,1557,25 648.05 Permit. (1) Permit required. After December 31, 2009, no care management organization may provide services to its enrollees without a permit under this chapter.

AB75,1558,2 (2) Application. A care management organization applying for a permit shall submit all of the following information in the format required by the commissioner:

AB75,1558,5 (a) The names, addresses and occupations of all controlling persons and directors and principal officers of the care management organization currently and for the preceding 10 years, unless the commissioner waives this requirement.

AB75,1558,7 (b) Business organization documents, including articles and bylaws if applicable.

AB75,1558,10 (c) A business plan approved by the department, including a projection of the anticipated operating results at the end of each of the next 3 years of operation, based on reasonable estimates of income and operating expenses.

AB75,1558,12 (d) Any other relevant documents or information that the commissioner reasonably requires after consulting with the department.

AB75,1558,15 (3) Standards for issuing permit. The commissioner may issue a permit to the care management organization if the commissioner finds, after consulting with the department, all of the following:

AB75,1558,16 (a) All requirements of law have been met.

AB75,1558,20 (b) All the directors and principal officers or any controlling person are trustworthy and competent and collectively have the competence and experience to engage in the proposed services and are not excluded from participation under 42 USC 1320a-7 or 42 USC 1320a-7a.

AB75,1558,22 (c) The business plan is consistent with the interests of the care management organization's enrollees and the public.

AB75,1558,25 (4) Suspension or revocation. The commissioner may suspend or revoke a permit issued under this chapter if the commissioner finds, after consulting with the department, any of the following:

AB75,1559,2 (a) The permittee violated a law or rule, including a rule establishing standards for the financial condition of care management organizations.