2009 - 2010 LEGISLATURE
December 3, 2009 - Introduced by Senators Sullivan, Kreitlow, Cowles, Miller,
Lehman, Vinehout, Taylor and Wirch, cosponsored by Representatives
Richards, Staskunas, Turner, Pope-Roberts, Hebl, Roys, A. Williams,
Soletski, Hraychuck, Krusick, Hilgenberg and Milroy. Referred to
Committee on Health, Health Insurance, Privacy, Property Tax Relief, and
1An Act to amend
40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.981 (4t) 2
and 185.983 (1) (intro.); and to create
146.903, 609.71 and 632.798 of the 3
statutes; relating to: disclosure of information by health care providers and
4insurers and providing a penalty.
Analysis by the Legislative Reference Bureau
This bill requires a health care provider to disclose to a consumer the provider's
median billed charge for a health care service, diagnostic test, or procedure, upon
request. The bill also requires a health care provider to disclose specified charge
information for the 25 presenting conditions for which the provider most frequently
provides services, as identified by the Department of Health Services (DHS). The bill
requires DHS to consult with the Wisconsin Collaborative for Healthcare Quality,
and to use Medical Assistance claims data, in identifying the presenting conditions
for each health care provider. Under the bill, a health care provider must create a
document that lists the following charge information for diagnosing and treating
each of the 25 presenting conditions identified by DHS for the provider: 1) the
provider's median billed charges; 2) the reimbursement amount under Medical
Assistance, if the health care provider participates in the Medical Assistance
Program; 3) the reimbursement amount under Medicare, if the provider participates
in Medicare; and 4) the average allowable payment from private, third-party payers.
A health care provider must update the document annually.
Under the bill, these provisions relating to disclosing charge information apply
to health care facilities such as a hospital, ambulatory surgical center, or nursing
home, and to associations of health care provides that include four or more
Under the bill, a self-insured health plan of the state or a county, city, village,
town, or school district, or an insurer that provides coverage under a health
insurance policy, including defined network plans and sickness care plans operated
by cooperative associations, must provide to an insured under the health insurance
policy or an enrollee under the self-insured health plan a good faith estimate of the
median reimbursement that the insurer or self-insured health plan would expect to
pay for a specified health care service in the geographic region in which the service
will be provided. In addition, the insurer or self-insured health plan must provide
to an insured or enrollee a good faith estimate of the insured's or enrollee's total
out-of-pocket cost for the specified service. The information must be provided only
if the insured or enrollee requests it, and it must be provided at no charge to the
insured or enrollee. Before providing any of the information, the insurer or
self-insured health plan may require the insured or enrollee to provide the name of
the provider providing the service, the facility at which the service will be provided,
the date the service will be provided, the provider's estimate of the charges, and the
Current Procedural Terminology code or Current Dental Terminology code for the
service. In addition, the bill provides that any good faith estimate provided is not a
legally binding estimate.
The bill also requires health care providers to display prominently statements
informing health care consumers of the consumers' right to receive charge
information from the health care providers and from their insurers.
For further information see the state 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:
Every health care coverage plan offered by the state under sub. (6) 4
shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) 5
and (10), 632.747, 632.748, 632.798,
632.83, 632.835, 632.85, 632.853, 632.855, 6
632.87 (3) to (6), 632.885, 632.895 (5m) and (8) to (17), and 632.896.
Every health care coverage plan offered by the group insurance 2
board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 3
632.83, 632.835, 632.85, 632.853, 632.855, 632.885, and 632.895 4
(11) to (17).
66.0137 (4) Self-insured health plans.
If a city, including a 1st class city, or 8
a village provides health care benefits under its home rule power, or if a town 9
provides health care benefits, to its officers and employees on a self-insured basis, 10
the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 11
632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798,
632.85, 632.853, 632.855, 632.87 12
(4), (5), and (6), 632.885, 632.895 (9) to (17), 632.896, and 767.513 (4).
(g) Every self-insured plan under par. (b) shall comply with ss. 16
49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 17632.798,
632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.895 (9) to 18
(17), 632.896, and 767.513 (4).
SB418, s. 5
146.903 of the statutes is created to read:
20146.903 Disclosures required of health care providers. (1) Definitions. 21
In this section:
(a) "Ambulatory surgical center" has the meaning given in 42 CFR 416.2
(b) "Clinic" means a place, other than a residence, that is used primarily for the 24
provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and 25
(c) "Health care provider" has the meaning given in s. 146.81 (1) (a) to (p) and 2
includes a clinic and an ambulatory surgical center.
(d) "Median billed charge" means the amount that a health care provider 4
charged for a health care service, diagnostic test, or procedure, before any discount 5
or contractual rate applicable to certain patients or payers was applied, during the 6
first 2 calendar quarters of the most recently completed calendar year, as calculated 7
by arranging the charges in that reporting period from highest to lowest and 8
selecting the middle charge in the sequence or, for an even number of charges, 9
selecting the 2 middle charges in the sequence and calculating the average of the 2.
(e) "Medical Assistance" means health care benefits provided under subch. IV 11
of ch. 49.
(f) "Medicare" means coverage under part A or part B of Title XVIII of the 13
federal Social Security Act, 42 USC 1395
14(2) Department duties.
(a) The department shall, for each health care provider 15
that is required to comply with sub. (4), annually identify the 25 presenting 16
conditions for which the health care provider most frequently provides health care 17
services. The department shall use claims data for Medical Assistance and shall 18
consult with the Wisconsin Collaborative for Healthcare Quality in identifying the 19
(b) The department shall, after consulting with the Wisconsin Collaborative for 21
Healthcare Quality, prescribe the methods by which a health care provider shall 22
calculate and present median billed charges and Medical Assistance, Medicare, and 23
private, 3rd-party payer payments for a presenting condition under this section.
24(3) Charge for a service.
Except as provided in sub. (6), a health care provider 25
or the health care provider's designee shall, upon request by and at no cost to a health
care consumer, disclose to the consumer within a reasonable period of time after the 2
request, the median billed charge, assuming no medical complications, for an 3
inpatient or outpatient health care service, diagnostic test, or procedure that is 4
specified by the consumer and that is provided by the health care provider.
5(4) Summary of charges for common services.
(a) Except as provided in sub. 6
(6), a health care provider shall prepare a single document that lists the following 7
charge information for diagnosing and treating each of the 25 presenting conditions 8
identified for the health care provider under sub. (2):
1. The median billed charges.
2. If the health care provider is certified as a provider of Medical Assistance, 11
the Medical Assistance payment to the provider.
3. If the health care provider is certified as a provider of Medicare, the Medicare 13
payment to the provider.
4. The average allowable payment from private, 3rd-party payers.
(b) Except as provided in sub. (6), a health care provider or the health care 16
provider's designee shall, upon request by and at no cost to a health care consumer, 17
provide the consumer a copy of the document prepared under par. (a).
(c) A health care provider shall annually update the document under par. (a).
(d) Charge information included on the document under par. (a) does not 20
constitute a legally binding estimate of the cost to the consumer.
Except as provided in sub. (6), a health care provider shall 22
prominently display, in the area of the health care provider's practice or facility that 23
is most commonly frequented by health care consumers, a statement informing the 24
consumers that they have the right to receive charge information as provided in subs.
(3) and (4) from the health care provider and, if the requirements under s. 632.798 2
(2) (e) are met, all of the following from their insurers or self-insured health plans:
(a) A good faith estimate of the median reimbursement that the insurer or 4
self-insured health plan would expect to pay for a specified health care service in the 5
geographic region in which the health care service will be provided.
(b) A good faith estimate of the insured's total out-of-pocket cost according to 7
the insured's benefit terms for the specified health care service in the geographic 8
region in which the health care service will be provided.
9(6) Applicability to health care providers.
The requirements under subs. (3) 10
to (5) do not apply to any of the following:
(a) A health care provider that practices individually and not in association 12
with another health care provider.
(b) Health care providers that are an association of 3 or fewer individual health 14
(a) Whoever violates this section may be required to forfeit not 16
more than $500 for each violation.
(b) The department may directly assess forfeitures provided for under par. (a). 18
If the department determines that a forfeiture should be assessed for a particular 19
violation, the department shall send a notice of assessment to the alleged violator. 20
The notice shall specify the amount of the forfeiture assessed, the violation, and the 21
statute or rule alleged to have been violated, and shall inform the alleged violator of 22
the right to a hearing under par. (c).
(c) An alleged violator may contest an assessment of a forfeiture by sending, 24
within 10 days after receipt of notice under par. (b), a written request for a hearing 25
under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1).
The administrator of the division may designate a hearing examiner to preside over 2
the case and recommend a decision to the administrator under s. 227.46. The 3
decision of the administrator of the division shall be the final administrative 4
decision. The division shall commence the hearing within 30 days after receipt of the 5
request for a hearing and shall issue a final decision within 15 days after the close 6
of the hearing. Proceedings before the division are governed by ch. 227. In any 7
petition for judicial review of a decision by the division, the party, other than the 8
petitioner, who was in the proceeding before the division shall be the named 9