2017 - 2018 LEGISLATURE
March 12, 2018 - Introduced by Representatives Anderson, Billings, Berceau,
Zamarripa, Sargent, Spreitzer, Sinicki, Subeck, Brostoff and Pope,
cosponsored by Senators Vinehout, Risser and Larson. Referred to
Committee on Insurance.
1An Act to create
609.048 of the statutes; relating to: evaluation of health plan
Analysis by the Legislative Reference Bureau
This bill requires the commissioner of insurance to determine sufficiency of the
network of providers of a defined network plan or preferred provider plan. Defined
network plans and preferred provider plans are types of managed care organizations
that provide health care benefits to their enrollees. The bill allows the commissioner
to require a plan to make accomodations for enrollees to obtain covered services if the
plan's network is not sufficient. The bill also specifies factors that the commissioner
is allowed to consider when considering whether a plan's network is sufficient.
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:
609.048 of the statutes is created to read:
4609.048 Network adequacy.
The commissioner shall determine sufficiency 5
of the defined network plan's or preferred provider plan's network to ensure that all 6
covered services are accessible to enrollees without unreasonable travel or delay.
The commissioner may require a defined network plan or preferred provider plan to 2
make accommodations for enrollees to obtain covered services if its network is not 3
sufficient. Factors the commissioner may consider when considering network 4
sufficiency may include any of the following:
The ratio of primary care providers to enrollees.
The geographic accessibility of providers.
The waiting time for an appointment with a provider of a particular 8
specialty who is in the network.
The ability of the network to meet the needs of the population of enrollees.
The extent to which providers in the network are accepting new patients.
Whether the plan has a process of ensuring that an enrollee is able to obtain 12
a covered service at an out-of-pocket cost that is the same as for a service provided 13
by a provider in the network if a provider in the network is not available to provide 14
the covered services without unreasonable travel or delay.