SB70-AA3,27 16Section 27. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:
SB70-AA3,46,1717 632.895 (14) (a) 1. k. Human papillomavirus.
SB70-AA3,46,1818 L. Meningococcal meningitis.
SB70-AA3,46,1919 m. Pneumococcal pneumonia.
SB70-AA3,46,2020 n. Influenza.
SB70-AA3,46,2121 o. Rotavirus.
SB70-AA3,28 22Section 28. 632.895 (14) (b) of the statutes is amended to read:
SB70-AA3,47,323 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy,
24and every self-insured health plan of the state or a county, city, town, village, or
25school district, that provides coverage for a dependent of the insured shall provide

1coverage of appropriate and necessary immunizations, from birth to the age of 6
2years,
for an insured or plan participant, including a dependent who is a child of the
3insured or plan participant.
SB70-AA3,29 4Section 29. 632.895 (14) (c) of the statutes is amended to read:
SB70-AA3,47,95 632.895 (14) (c) The coverage required under par. (b) may not be subject to any
6deductibles, copayments, or coinsurance under the policy or plan. This paragraph
7applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to
8appropriate and necessary immunizations provided by providers participating, as
9defined in s. 609.01 (3m), in the plan.
SB70-AA3,30 10Section 30. 632.895 (14) (d) 3. of the statutes is amended to read:
SB70-AA3,47,1311 632.895 (14) (d) 3. A health care plan offered by a limited service health
12organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined
13in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b)
.
SB70-AA3,31 14Section 31. 632.895 (14m) of the statutes is created to read:
SB70-AA3,47,1615 632.895 (14m) Essential health benefits. (a) In this subsection,
16“self-insured health plan” has the meaning given in s. 632.85 (1) (c).
SB70-AA3,47,2017 (b) On a date specified by the commissioner, by rule, every disability insurance
18policy, except as provided in par. (g), and every self-insured health plan shall provide
19coverage for essential health benefits as determined by the commissioner, by rule,
20subject to par. (c).
SB70-AA3,47,2221 (c) In determining the essential health benefits for which coverage is required
22under par. (b), the commissioner shall do all of the following:
SB70-AA3,47,2423 1. Include benefits, items, and services in, at least, all of the following
24categories:
SB70-AA3,47,2525 a. Ambulatory patient services.
SB70-AA3,48,1
1b. Emergency services.
SB70-AA3,48,22 c. Hospitalization.
SB70-AA3,48,33 d. Maternity and newborn care.
SB70-AA3,48,54 e. Mental health and substance use disorder services, including behavioral
5health treatment.
SB70-AA3,48,66 f. Prescription drugs.
SB70-AA3,48,77 g. Rehabilitative and habilitative services and devices.
SB70-AA3,48,88 h. Laboratory services.
SB70-AA3,48,99 i. Preventive and wellness services and chronic disease management.
SB70-AA3,48,1010 j. Pediatric services, including oral and vision care.
SB70-AA3,48,1511 2. Conduct a survey of employer-sponsored coverage to determine benefits
12typically covered by employers and ensure that the scope of essential health benefits
13for which coverage is required under this subsection is equal to the scope of benefits
14covered under a typical disability insurance policy offered by an employer to its
15employees.
SB70-AA3,48,1716 3. Ensure that essential health benefits reflect a balance among the categories
17described in subd. 1. such that benefits are not unduly weighted toward one category.
SB70-AA3,48,1918 4. Ensure that essential health benefit coverage is provided with no or limited
19cost-sharing requirements.
SB70-AA3,48,2320 5. Require that disability insurance policies and self-insured health plans do
21not make coverage decisions, determine reimbursement rates, establish incentive
22programs, or design benefits in ways that discriminate against individuals because
23of their age, disability, or expected length of life.
SB70-AA3,49,3
16. Establish essential health benefits in a way that takes into account the
2health care needs of diverse segments of the population, including women, children,
3persons with disabilities, and other groups.
SB70-AA3,49,74 7. Ensure that essential health benefits established under this subsection are
5not subject to a coverage denial based on an insured's or plan participant's age,
6expected length of life, present or predicted disability, degree of dependency on
7medical care, or quality of life.
SB70-AA3,49,148 8. Require that disability insurance policies and self-insured health plans
9cover emergency department services that are essential health benefits without
10imposing any requirement to obtain prior authorization for those services and
11without limiting coverage for services provided by an emergency services provider
12that is not in the provider network of a policy or plan in a way that is more restrictive
13than requirements or limitations that apply to emergency services provided by a
14provider that is in the provider network of the policy or plan.
SB70-AA3,49,1915 9. Require a disability insurance policy or self-insured health plan to apply to
16emergency department services that are essential health benefits provided by an
17emergency department provider that is not in the provider network of the policy or
18plan the same copayment amount or coinsurance rate that applies if those services
19are provided by a provider that is in the provider network of the policy or plan.
SB70-AA3,49,2120 (d) The commissioner shall periodically update, by rule, the essential health
21benefits under this subsection to address any gaps in access to coverage.
SB70-AA3,50,222 (e) If an essential health benefit is also subject to mandated coverage elsewhere
23under this section and the coverage requirements are not identical, the disability
24insurance policy or self-insured health plan shall provide coverage under whichever

1subsection provides the insured or plan participant with more comprehensive
2coverage of the medical condition, item, or service.
SB70-AA3,50,63 (f) Nothing in this subsection or rules promulgated under this subsection
4prohibits a disability insurance policy or a self-insured health plan from providing
5benefits in excess of the essential health benefit coverage required under this
6subsection.
SB70-AA3,50,87 (g) This subsection does not apply to any disability insurance policy that is
8described in s. 632.745 (11) (b) 1. to 12.
SB70-AA3,32 9Section 32. 632.895 (16m) (b) of the statutes is amended to read:
SB70-AA3,50,1410 632.895 (16m) (b) The coverage required under this subsection may be subject
11to any limitations, or exclusions , or cost-sharing provisions that apply generally
12under the disability insurance policy or self-insured health plan. The coverage
13required under this subsection may not be subject to any deductibles, copayments,
14or coinsurance.
SB70-AA3,33 15Section 33. 632.895 (17) (b) 2. of the statutes is amended to read:
SB70-AA3,50,2016 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and
17medical services that are necessary to prescribe, administer, maintain, or remove a
18contraceptive, if covered for any other drug benefits under the policy or plan
19sterilization procedures, and patient education and counseling for all females with
20reproductive capacity
.
SB70-AA3,34 21Section 34. 632.895 (17) (c) of the statutes is amended to read:
SB70-AA3,51,1122 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions,
23and limitations, or cost-sharing provisions that apply generally to the coverage of
24outpatient health care services, preventive treatments and services, or prescription
25drugs and devices that is provided under the policy or self-insured health plan. A

1disability insurance policy or self-insured health plan may not apply a deductible or
2impose a copayment or coinsurance to at least one of each type of contraceptive
3method approved by the federal food and drug administration for which coverage is
4required under this subsection. The disability insurance policy or self-insured
5health plan may apply reasonable medical management to a method of contraception
6to limit coverage under this subsection that is provided without being subject to a
7deductible, copayment, or coinsurance to prescription drugs without a brand name.
8The disability insurance policy or self-insured health plan may apply a deductible
9or impose a copayment or coinsurance for coverage of a contraceptive that is
10prescribed for a medical need if the services for the medical need would otherwise be
11subject to a deductible, copayment, or coinsurance.
SB70-AA3,35 12Section 35. 632.897 (11) (a) of the statutes is amended to read:
SB70-AA3,51,2113 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may
14promulgate rules establishing standards requiring insurers to provide continuation
15of coverage for any individual covered at any time under a group policy who is a
16terminated insured or an eligible individual under any federal program that
17provides for a federal premium subsidy for individuals covered under continuation
18of coverage under a group policy, including rules governing election or extension of
19election periods, notice, rates, premiums, premium payment, application of
20preexisting condition exclusions,
election of alternative coverage, and status as an
21eligible individual, as defined in s. 149.10 (2t), 2011 stats.
SB70-AA3,9323 22Section 9323. Initial applicability; Insurance.
SB70-AA3,51,2423 (1u) Coverage of individuals with preexisting conditions, essential health
24benefits, and preventive services.
SB70-AA3,52,7
1(a) For policies and plans containing provisions inconsistent with these
2sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e),
3(3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac)
41. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c),
5and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies
6to policy or plan years beginning on January 1 of the year following the year in which
7this paragraph takes effect, except as provided in par. (b).
SB70-AA3,52,158 (b) For policies and plans that are affected by a collective bargaining agreement
9containing provisions inconsistent with these sections, the treatment of ss. 632.728,
10632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8)
11(a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8)
12(d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17)
13(b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on
14the effective date of this paragraph or on the day on which the collective bargaining
15agreement is entered into, extended, modified, or renewed, whichever is later.
SB70-AA3,9423 16Section 9423. Effective dates; Insurance.
SB70-AA3,52,2317 (1v) Coverage of individuals with preexisting conditions, essential health
18benefits, and preventive services.
The treatment of ss. 632.728, 632.746 (1) (a) and
19(b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748
20(2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1.
21i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897
22(11) (a) and Section 9323 (1u) of this act take effect on the first day of the 4th month
23beginning after publication.”.
SB70-AA3,52,24 24180. Page 374, line 11: after that line insert:
SB70-AA3,53,1
1 Section 36. 609.20 (3) of the statutes is created to read:
SB70-AA3,53,82 609.20 (3) The commissioner may promulgate rules to establish minimum
3network time and distance standards and minimum network wait-time standards
4for defined network plans and preferred provider plans. In promulgating rules
5under this subsection, the commissioner shall consider standards adopted by the
6federal centers for medicare and medicaid services for qualified health plans, as
7defined in 42 USC 18021 (a), that are offered through the federal health insurance
8exchange established pursuant to 42 USC 18041 (c).”.
SB70-AA3,53,9 9181. Page 374, line 11: after that line insert:
SB70-AA3,53,10 10 Section 37. 609.045 of the statutes is created to read:
SB70-AA3,53,12 11609.045 Balance billing; emergency medical services. (1) Definitions.
12In this section:
SB70-AA3,53,1313 (a) “Emergency medical condition” means all of the following:
SB70-AA3,53,1714 1. A medical condition, including a mental health condition or substance use
15disorder condition, manifesting itself by acute symptoms of sufficient severity,
16including severe pain, such that the absence of immediate medical attention could
17reasonably be expected to result in any of the following:
SB70-AA3,53,1918 a. Placing the health of the individual or, with respect to a pregnant woman,
19the health of the woman or her unborn child, in serious jeopardy.
SB70-AA3,53,2020 b. Serious impairment of bodily function.
SB70-AA3,53,2121 c. Serious dysfunction of any bodily organ or part.
SB70-AA3,54,222 2. With respect to a pregnant woman who is having contractions, a medical
23condition for which there is inadequate time to safely transfer the pregnant woman

1to another hospital before delivery or for which the transfer may pose a threat to the
2health or safety of the pregnant woman or the unborn child.
SB70-AA3,54,53 (b) “Emergency medical services,” with respect to an emergency medical
4condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a)
5(3) (C).
SB70-AA3,54,76 (c) “Independent freestanding emergency department" has the meaning given
7in 42 USC 300gg-111 (a) (3) (D).
SB70-AA3,54,98 (d) “Out-of-network rate” has the meaning given by the commissioner by rule
9or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).
SB70-AA3,54,1310 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
11preferred provider plan, as defined in s. 609.01 (4), that has a network of
12participating providers and imposes on enrollees different requirements for using
13providers that are not participating providers.
SB70-AA3,54,1514 (f) “Recognized amount” has the meaning given by the commissioner by rule
15or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).
SB70-AA3,54,1916 (g) “Self-insured governmental plan” means a self-insured health plan of the
17state or a county, city, village, town, or school district that has a network of
18participating providers and imposes on enrollees in the self-insured health plan
19different requirements for using providers that are not participating providers.
SB70-AA3,54,2220 (h) “Terminated” means the expiration or nonrenewal of a contract.
21“Terminated” does not include a termination of a contract for failure to meet
22applicable quality standards or for fraud.
SB70-AA3,55,2 23(2) Emergency medical services. A defined network plan, preferred provider
24plan, or self-insured governmental plan that covers any benefits or services provided
25in an emergency department of a hospital or emergency medical services provided

1in an independent freestanding emergency department shall cover emergency
2medical services in accordance with all of the following:
SB70-AA3,55,33 (a) The plan may not require a prior authorization determination.
SB70-AA3,55,64 (b) The plan may not deny coverage on the basis of whether or not the health
5care provider providing the services is a participating provider or participating
6emergency facility.
SB70-AA3,55,97 (c) If the emergency medical services are provided to an enrollee by a provider
8or in a facility that is not a participating provider or participating facility, the plan
9complies with all of the following:
SB70-AA3,55,1310 1. The emergency medical services are covered without imposing on an enrollee
11a requirement for prior authorization or any coverage limitation that is more
12restrictive than requirements or limitations that apply to emergency medical
13services provided by participating providers or in participating facilities.
SB70-AA3,55,1714 2. Any cost-sharing requirement imposed on an enrollee for the emergency
15medical services is no greater than the requirements that would apply if the
16emergency medical services were provided by a participating provider or in a
17participating facility.
SB70-AA3,55,2218 3. Any cost-sharing amount imposed on an enrollee for the emergency medical
19services is calculated as if the total amount that would have been charged for the
20emergency medical services if provided by a participating provider or in a
21participating facility is equal to the recognized amount for such services, plan or
22coverage, and year.
SB70-AA3,55,2323 4. The plan does all of the following:
SB70-AA3,56,3
1a. No later than 30 days after the participating provider or participating facility
2transmits to the plan the bill for emergency medical services, sends to the provider
3or facility an initial payment or a notice of denial of payment.
SB70-AA3,56,64 b. Pays to the participating provider or participating facility a total amount
5that, incorporating any initial payment under subd. 4. a., is equal to the amount by
6which the out-of-network rate exceeds the cost-sharing amount.
SB70-AA3,56,117 5. The plan counts any cost-sharing payment made by the enrollee for the
8emergency medical services toward any in-network deductible or out-of-pocket
9maximum applied by the plan in the same manner as if the cost-sharing payment
10was made for emergency medical services provided by a participating provider or in
11a participating facility.
SB70-AA3,56,17 12(3) Nonparticipating provider in participating facility. For items or services
13other than emergency medical services that are provided to an enrollee of a defined
14network plan, preferred provider plan, or self-insured governmental plan by a
15provider who is not a participating provider but who is providing services at a
16participating facility, the plan shall provide coverage for the item or service in
17accordance with all of the following:
SB70-AA3,56,2018 (a) The plan may not impose on an enrollee a cost-sharing requirement for the
19item or service that is greater than the cost-sharing requirement that would have
20been imposed if the item or service was provided by a participating provider.
SB70-AA3,56,2421 (b) Any cost-sharing amount imposed on an enrollee for the item or service is
22calculated as if the total amount that would have been charged for the item or service
23if provided by a participating provider is equal to the recognized amount for such
24item or service, plan or coverage, and year.
SB70-AA3,57,2
1(c) No later than 30 days after the provider transmits the bill for services, the
2plan shall send to the provider an initial payment or a notice of denial of payment.
SB70-AA3,57,63 (d) The plan shall make a total payment directly to the provider who provided
4the item or service to the enrollee that, added to any initial payment described under
5par. (c), is equal to the amount by which the out-of-network rate for the item or
6service exceeds the cost-sharing amount.
SB70-AA3,57,107 (e) The plan counts any cost-sharing payment made by the enrollee for the item
8or service toward any in-network deductible or out-of-pocket maximum applied by
9the plan in the same manner as if the cost-sharing payment was made for the item
10or service when provided by a participating provider.
Loading...
Loading...