AB68: Bill Text

AB68,1571,6 (c) Subject to par. (d), no disability insurance policy and no self-insured health plan may subject the coverage of any of the preventive services under par. (b) to any deductibles, copayments, or coinsurance under the policy or plan.

AB68,1571,10 (d) 1. If an office visit and a preventive service specified under par. (b) are billed separately by the health care provider, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit but not on the preventive service.

AB68,1571,13 2. If the primary reason for an office visit is not to obtain a preventive service, the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit.

AB68,1571,23 3. Except as otherwise provided in this subdivision, if a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers, the policy or plan may apply deductibles to and impose copayments or coinsurance on the office visit and the preventive service. If a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy's or self-insured health plan's network of providers because there is no available health care provider in the policy's or plan's network of providers that provides the preventive service, the policy or plan may not apply deductibles to or impose copayments or coinsurance on the preventive service.

AB68,1572,3 4. If multiple well-woman visits described under par. (b) 47. are required to fulfill all necessary preventive services and are in accordance with clinical recommendations, the disability insurance policy or self-insured health plan may not apply a deductible to or impose a copayment or coinsurance on any of those well-woman visits.

AB68,2977 Section 2977. 632.895 (14) (a) 1. i. and j. of the statutes are amended to read:

AB68,1572,5 632.895 (14) (a) 1. i. Hepatitis A and B.

AB68,1572,6 j. Varicella and herpes zoster.

AB68,2978 Section 2978. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:

AB68,1572,8 632.895 (14) (a) 1. k. Human papillomavirus.

AB68,1572,9 L. Meningococcal meningitis.

AB68,1572,10 m. Pneumococcal pneumonia.

AB68,1572,11 n. Influenza.

AB68,1572,12 o. Rotavirus.

AB68,2979 Section 2979. 632.895 (14) (b) of the statutes is amended to read:

AB68,1572,19 632.895 (14) (b) Except as provided in par. (d), 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 dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for an insured or plan participant, including a dependent who is a child of the insured or plan participant.

AB68,2980 Section 2980. 632.895 (14) (c) of the statutes is amended to read:

AB68,1572,25 632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

AB68,2981 Section 2981. 632.895 (14) (d) 3. of the statutes is amended to read:

AB68,1573,4 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB68,2982 Section 2982. 632.895 (14m) of the statutes is created to read:

AB68,1573,7 632.895 (14m) Essential health benefits. (a) In this subsection, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68,1573,11 (b) On a date specified by the commissioner, by rule, every disability insurance policy, except as provided in par. (g), and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB68,1573,13 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB68,1573,15 1. Include benefits, items, and services in, at least, all of the following categories:

AB68,1573,16 a. Ambulatory patient services.

AB68,1573,17 b. Emergency services.

AB68,1573,18 c. Hospitalization.

AB68,1573,19 d. Maternity and newborn care.

AB68,1573,21 e. Mental health and substance use disorder services, including behavioral health treatment.

AB68,1573,22 f. Prescription drugs.

AB68,1573,23 g. Rehabilitative and habilitative services and devices.

AB68,1573,24 h. Laboratory services.

AB68,1573,25 i. Preventive and wellness services and chronic disease management.

AB68,1574,1 j. Pediatric services, including oral and vision care.

AB68,1574,6 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.

AB68,1574,8 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.

AB68,1574,10 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB68,1574,14 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.

AB68,1574,17 6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB68,1574,21 7. Ensure that essential health benefits established under this subsection are not 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.

AB68,1575,3 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.

AB68,1575,8 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.

AB68,1575,10 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB68,1575,15 (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.

AB68,1575,19 (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.

AB68,1575,21 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

AB68,2983 Section 2983. 632.895 (16m) (b) of the statutes is amended to read:

AB68,1576,2 632.895 (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.

AB68,2984 Section 2984. 632.895 (17) (b) 2. of the statutes is amended to read:

AB68,1576,8 632.895 (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.

AB68,2985 Section 2985. 632.895 (17) (c) of the statutes is amended to read:

AB68,1576,24 632.895 (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.

AB68,2986 Section 2986. 632.897 (11) (a) of the statutes is amended to read:

AB68,1577,9 632.897 (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.

AB68,2987 Section 2987 . Chapter 633 (title) of the statutes is amended to read:

AB68,1577,14 CHAPTER 633 EMPLOYEE BENEFIT PLAN ADMINISTRATORS AND, PRINCIPALS , and Pharmacy benefit managers

AB68,2988 Section 2988 . 633.01 (1) (intro.) and (c) of the statutes are amended to read:

AB68,1577,19 633.01 (1) (intro.) “Administrator" means a person who directly or indirectly solicits or collects premiums or charges or otherwise effects coverage or adjusts or settles claims for a an employee benefit plan, but does not include the following persons if they perform these acts under the circumstances specified for each:

AB68,1577,22 (c) A creditor on behalf of its debtor, if to obtain payment, reimbursement or other method of satisfaction from a an employee benefit plan for any part of a debt owed to the creditor by the debtor.

AB68,2989 Section 2989 . 633.01 (2r) of the statutes is created to read:

AB68,1577,24 633.01 (2r) “Enrollee” has the meaning given in s. 632.861 (1) (b).

AB68,2990 Section 2990 . 633.01 (3) of the statutes is amended to read:

AB68,1578,2 633.01 (3) “Insured employee" means an employee who is a resident of this state and who is covered under a an employee benefit plan.

AB68,2991 Section 2991 . 633.01 (4) of the statutes is renumbered 633.01 (2g) and amended to read:

AB68,1578,10 633.01 (2g) “Plan Employee benefit plan" means an insured or wholly or partially self-insured employee benefit plan which by means of direct payment, reimbursement or other arrangement provides to one or more employees who are residents of this state benefits or services that include, but are not limited to, benefits for medical, surgical or hospital care, benefits in the event of sickness, accident, disability or death, or benefits in the event of unemployment or retirement.

AB68,2992 Section 2992 . 633.01 (4g) of the statutes is created to read:

AB68,1578,13 633.01 (4g) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB68,2993 Section 2993 . 633.01 (4r) of the statutes is created to read:

AB68,1578,16 633.01 (4r) “Prescription drug benefit” has the meaning given in s. 632.865 (1) (e).

AB68,2994 Section 2994 . 633.01 (5) of the statutes is amended to read:

AB68,1578,19 633.01 (5) “Principal" means a person, including an insurer, that uses the services of an administrator to provide a an employee benefit plan.

AB68,2995 Section 2995 . 633.01 (6) of the statutes is created to read:

AB68,1578,21 633.01 (6) “Self-insured health plan" has the meaning given in s. 632.85 (1) (c).

AB68,2996 Section 2996 . 633.04 (intro.) of the statutes is amended to read:

AB68,1579,2 633.04 Written agreement required. (intro.) An administrator may not administer a an employee benefit plan in the absence of a written agreement between the administrator and a principal. The administrator and principal shall each retain a copy of the written agreement for the duration of the agreement and for 5 years thereafter. The written agreement shall contain the following terms:

AB68,2997 Section 2997 . 633.05 of the statutes is amended to read:

AB68,1579,10 633.05 Payment to administrator. If a principal is an insurer, payment to the administrator of a premium or charge by or on behalf of an insured employee is payment to the insurer, but payment of a return premium or claim by the insurer to the administrator is not payment to an insured employee until the payment is received by the insured employee. This section does not limit any right of the insurer against the administrator for failure to make payments to the insurer or an insured employee.

AB68,2998 Section 2998 . 633.06 of the statutes is amended to read:

AB68,1579,16 633.06 Examination and inspection of books and records. (1) The commissioner may examine, audit or accept an audit of the books and records of an administrator or pharmacy benefit manager as provided for examination of licensees under s. 601.43 (1), (3), (4) and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

AB68,1579,20 (2) A principal that uses an administrator may inspect the books and records of the administrator, subject to any restrictions set forth in ss. 146.81 to 146.835 and in the written agreement required under s. 633.04, for the purpose of enabling the principal to fulfill its contractual obligations to insureds insured employees.

AB68,2999 Section 2999 . 633.07 of the statutes is amended to read:

AB68,1579,24 633.07 Approval of advertising. An administrator may not use any advertising for a an employee benefit plan underwritten by an insurer unless the insurer approves the advertising in advance.

AB68,3000 Section 3000 . 633.09 (4) (b) 2. and 3. of the statutes are amended to read:

AB68,1580,2 633.09 (4) (b) 2. To a an employee benefit plan policyholder for payment to a principal, the funds belonging to the principal.

AB68,1580,3 3. To an insured employee, the funds belonging to the insured employee.

AB68,3001 Section 3001 . 633.11 of the statutes is amended to read:

AB68,1580,10 633.11 Claim adjustment compensation. If an administrator adjusts or settles claims under a an employee benefit plan, the commission, fees or charges that the principal pays the administrator may not be based on the employee benefit plan's loss experience. This section does not prohibit compensation based on the number or amount of premiums or charges collected, or the number or amount of claims paid or processed by the administrator.

AB68,3002 Section 3002 . 633.12 (1) (intro.), (b) and (c) of the statutes are amended to read: