Amendment SA2-SSA2-AB365

AB365-SSA2-SA2,17,23 632.895 (14m) Essential health benefits. (a) In this section, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB365-SSA2-SA2,18,3 (b) On a date specified by the commissioner, by rule, every disability insurance policy and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB365-SSA2-SA2,18,5 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB365-SSA2-SA2,18,7 1. Include benefits, items, and services in, at least, all of the following categories:

AB365-SSA2-SA2,18,8 a. Ambulatory patient services.

AB365-SSA2-SA2,18,9 b. Emergency services.

AB365-SSA2-SA2,18,10 c. Hospitalization.

AB365-SSA2-SA2,18,11 d. Maternity and newborn care.

AB365-SSA2-SA2,18,13 e. Mental health and substance use disorder services, including behavioral health treatment.

AB365-SSA2-SA2,18,14 f. Prescription drugs.

AB365-SSA2-SA2,18,15 g. Rehabilitative and habilitative services and devices.

AB365-SSA2-SA2,18,16 h. Laboratory services.

AB365-SSA2-SA2,18,17 i. Preventive and wellness services and chronic disease management.

AB365-SSA2-SA2,18,18 j. Pediatric services, including oral and vision care.

AB365-SSA2-SA2,18,23 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB365-SSA2-SA2,18,25 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB365-SSA2-SA2,19,2 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB365-SSA2-SA2,19,6 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB365-SSA2-SA2,19,9 6. Establish essential health benefits in a way that takes account of the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB365-SSA2-SA2,19,13 7. Ensure that essential health benefits established under this subsection not be subject to a coverage denial based on an insured's or plan participant's age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB365-SSA2-SA2,19,20 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB365-SSA2-SA2,19,25 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB365-SSA2-SA2,20,2 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB365-SSA2-SA2,20,7 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB365-SSA2-SA2,20,11 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.

AB365-SSA2-SA2,41 Section 41. 632.895 (16m) (b) of the statutes is amended to read:

AB365-SSA2-SA2,20,17 632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions , or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.

AB365-SSA2-SA2,42 Section 42. 632.895 (17) (b) 2. of the statutes is amended to read:

AB365-SSA2-SA2,20,23 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.

AB365-SSA2-SA2,43 Section 43. 632.895 (17) (c) of the statutes is amended to read:

AB365-SSA2-SA2,21,15 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions, and limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan. A disability insurance policy or self-insured health plan may not apply a deductible or impose a copayment or coinsurance to at least one of each type of contraceptive method approved by the federal food and drug administration for which coverage is required under this subsection. The disability insurance policy or self-insured health plan may apply reasonable medical management to a method of contraception to limit coverage under this subsection that is provided without being subject to a deductible, copayment, or coinsurance to prescription drugs without a brand name. The disability insurance policy or self-insured health plan may apply a deductible or impose a copayment or coinsurance for coverage of a contraceptive that is prescribed for a medical need if the services for the medical need would otherwise be subject to a deductible, copayment, or coinsurance.

AB365-SSA2-SA2,44 Section 44. 632.897 (11) (a) of the statutes is amended to read:

AB365-SSA2-SA2,21,25 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t), 2011 stats.

AB365-SSA2-SA2,45 Section 45. Initial applicability.

AB365-SSA2-SA2,22,4 (1) (a) For policies and plans containing provisions inconsistent with this act, the act first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

AB365-SSA2-SA2,22,9 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with this act, this act first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.

AB365-SSA2-SA2,46 Section 46. Effective date.

AB365-SSA2-SA2,22,12 (1) This act takes effect on the first day of the 4th month beginning after publication, except as follows:

AB365-SSA2-SA2,22,14 (a) The treatment of ss. 49.45 (23) (a) and 49.471 (1) (cr), (4) (a) 4. b., and (4g) takes effect on July 1, 2018.”.

AB365-SSA2-SA2,22,15 (End)