AB75: Bill Text

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.

AB75,1559,3 (b) The permittee is in a financially hazardous condition.

AB75,1559,5 (c) The permittee is controlled or managed by persons who are incompetent or untrustworthy.

AB75,1559,6 (d) The permittee conceals records from the commissioner.

AB75,1559,7 (e) The permittee's business plan is not in the public interest or is not prudent.

AB75,1559,9 (f) The permittee ceases to be certified by or maintain a contract with the department.

AB75,1559,11 648.10 Powers and duties of the commissioner. The commissioner may do any of the following:

AB75,1559,14 (1) Promulgate rules that are necessary to carry out the intent of this chapter, including, after consulting with the department, standards for the financial condition of care management organizations.

AB75,1559,18 (2) Use the authority granted under ss. 601.41, 601.42, 601.43, 601.44, 601.61, 601.62, 601.63, and 601.64, including the authority to issue orders, to enforce this chapter and to ensure that a care management organization has sufficient financial resources.

AB75,1559,20 648.15 Reports and replies. (1) Reports. The commissioner may require from any care management organization any of the following:

AB75,1559,23 (a) Statements, reports, answers to questionnaires, and other information in whatever reasonable form the commissioner designates and at such reasonable intervals as the commissioner chooses, or from time to time.

AB75,1559,25 (b) Full explanation of the programming of any data storage or communication system in use.

AB75,1560,3 (c) Information from any books, records, electronic data processing systems, computers, or any other information storage system at any reasonable time in any reasonable manner.

AB75,1560,5 (d) Statements, reports, audits, or certification from a certified public accountant or an actuary approved by the commissioner.

AB75,1560,8 (2) Forms. The commissioner, after consulting with the department, may prescribe forms for the reports under sub. (1) and specify who shall execute or certify such reports.

AB75,1560,12 (3) Accounting methods. The commissioner, after consulting with the department, may prescribe reasonable minimum standards and techniques of accounting and data handling to ensure that timely and reliable information will exist and will be available to the commissioner.

AB75,1560,18 (4) Replies. Any officer or manager of a care management organization, any person controlling or having a contract under which the person has a right to control a care management organization, whether exclusively or otherwise, or any person with executive authority over or in charge of any segment of such a care management organization's affairs, shall reply promptly in writing or in another designated form, to any written inquiry from the commissioner requesting a reply.

AB75,1560,20 (5) Verification. The commissioner may require that any communication made to the commissioner under this section be verified.

AB75,1560,23 (6) Immunity. In the absence of actual malice, no person shall be subject to damages in an action for defamation based on a communication to the commissioner required by law under this chapter or by the commissioner under this chapter.

AB75,1561,5 (7) Experts. The commissioner may employ experts to assist the commissioner in an examination or in the review of any transaction subject to approval under this chapter. The care management organization that is the subject of the examination, or that is a party to a transaction under review, including the person acquiring, controlling, or attempting to acquire the care management organization, shall pay the reasonable costs incurred by the commissioner for the expert and related expenses.

AB75,1561,8 648.20 Examinations. (1) Power to examine. (a) To inform himself or herself about a matter related to the enforcement of this chapter, the commissioner may examine the affairs and condition of any permittee.

AB75,1561,11 (b) So far as reasonably necessary for an examination under par. (a), the commissioner may examine the accounts, records, or documents so far as they relate to the permittee, of any of the following: