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.
SB70-AA3,57,16 11(4) Charging for services by nonparticipating provider; notice and consent.
12(a) Except as provided in par. (c), a provider of an item or service who is entitled to
13payment under sub. (3) may not bill or hold liable an enrollee for any amount for the
14item or service that is more than the cost-sharing amount calculated under sub. (3)
15(b) for the item or service unless the nonparticipating provider provides notice and
16obtains consent in accordance with all of the following:
SB70-AA3,57,1917 1. The notice states that the provider is not a participating provider in the
18enrollee's defined network plan, preferred provider plan, or self-insured
19governmental plan.
SB70-AA3,57,2320 2. The notice provides a good faith estimate of the amount that the
21nonparticipating provider may charge the enrollee for the item or service involved,
22including notification that the estimate does not constitute a contract with respect
23to the charges estimated for the item or service.
SB70-AA3,58,3
13. The notice includes a list of the participating providers at the participating
2facility who would be able to provide the item or service and notification that the
3enrollee may be referred to one of those participating providers.
SB70-AA3,58,64 4. The notice includes information about whether or not prior authorization or
5other care management limitations may be required before receiving an item or
6service at the participating facility.
SB70-AA3,58,87 5. The notice clearly states that consent is optional and that the patient may
8elect to seek care from an in-network provider.
SB70-AA3,58,99 6. The notice is worded in plain language.
SB70-AA3,58,1110 7. The notice is available in languages other than English. The commissioner
11shall identify languages for which the notice should be available.
SB70-AA3,58,1612 8. The enrollee provides consent to the nonparticipating provider to be treated
13by the nonparticipating provider, and the consent acknowledges that the enrollee
14has been informed that the charge paid by the enrollee may not meet a limitation that
15the enrollee's defined network plan, preferred provider plan, or self-insured
16governmental plan places on cost sharing, such as an in-network deductible.
SB70-AA3,58,1817 9. A signed copy of the consent described under subd. 8. is provided to the
18enrollee.
SB70-AA3,58,2019 (b) To be considered adequate, the notice and consent under par. (a) shall meet
20one of the following requirements, as applicable:
SB70-AA3,58,2421 1. If the enrollee makes an appointment for the item or service at least 72 hours
22before the day on which the item or service is to be provided, any notice under par.
23(a) shall be provided to the enrollee at least 72 hours before the day of the
24appointment at which the item or service is to be provided.
SB70-AA3,59,3
12. If the enrollee makes an appointment for the item or service less than 72
2hours before the day on which the item or service is to be provided, any notice under
3par. (a) shall be provided to the enrollee on the day that the appointment is made.
SB70-AA3,59,94 (c) A provider of an item or service who is entitled to payment under sub. (3)
5may not bill or hold liable an enrollee for any amount for an ancillary item or service
6that is more than the cost-sharing amount calculated under sub. (3) (b) for the item
7or service, whether or not provided by a physician or non-physician practitioner,
8unless the commissioner specifies by rule that the provider may balance bill for the
9ancillary item or service, if the item or service is any of the following:
SB70-AA3,59,1010 1. Related to an emergency medical service.
SB70-AA3,59,1111 2. Anesthesiology.
SB70-AA3,59,1212 3. Pathology.
SB70-AA3,59,1313 4. Radiology.
SB70-AA3,59,1414 5. Neonatology.
SB70-AA3,59,1615 6. An item or service provided by an assistant surgeon, hospitalist, or
16intensivist.
SB70-AA3,59,1717 7. A diagnostic service, including a radiology or laboratory service.
SB70-AA3,59,1918 8. An item or service provided by a specialty practitioner that the commissioner
19specifies by rule.
SB70-AA3,59,2220 9. An item or service provided by a nonparticipating provider when there is no
21participating provider who can furnish the item or service at the participating
22facility.
SB70-AA3,59,2523 (d) Any notice and consent provided under par. (a) may not extend to items or
24services furnished as a result of unforeseen, urgent medical needs that arise at the
25time the item or service is provided.
SB70-AA3,60,2
1(e) Any consent provided under par. (a) shall be retained by the provider for no
2less than 7 years.
SB70-AA3,60,12 3(5) Notice by provider or facility. Beginning no later than January 1, 2024,
4a health care provider or health care facility shall make available, including posting
5on a website, to enrollees in defined network plans, preferred provider plans, and
6self-insured governmental plans notice of the requirements on a provider or facility
7under sub. (4), of any other applicable state law requirements on the provider or
8facility with respect to charging an enrollee for an item or service if the provider or
9facility does not have a contractual relationship with the plan, and of information on
10contacting appropriate state or federal agencies in the event the enrollee believes the
11provider or facility violates any of the requirements under this section or other
12applicable law.
SB70-AA3,61,4 13(6) Negotiation; dispute resolution. A provider or facility that is entitled to
14receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may
15initiate, within 30 days of receiving the initial payment or notice of denial, open
16negotiations with the defined network plan, preferred provider plan, or self-insured
17governmental plan to determine a payment amount for an emergency medical
18service or other item or service for a period that terminates 30 days after initiating
19open negotiations. If the open negotiation period under this subsection terminates
20without determination of a payment amount, the provider, facility, defined network
21plan, preferred provider plan, or self-insured governmental plan may initiate,
22within the 4 days beginning on the day after the open negotiation period ends, the
23independent dispute resolution process as specified by the commissioner. If the
24independent dispute resolution decision-maker determines the payment amount,
25the party to the independent dispute resolution process whose amount was not

1selected shall pay the fees for the independent dispute resolution. If the parties to
2the independent dispute resolution reach a settlement on the payment amount, the
3parties to the independent dispute resolution shall equally divide the payment for
4the fees for the independent dispute resolution.
SB70-AA3,61,5 5(7) Continuity of care. (a) In this subsection:
SB70-AA3,61,66 1. “Continuing care patient” means an individual who is any of the following:
SB70-AA3,61,87 a. Undergoing a course of treatment for a serious and complex condition from
8a provider or facility.
SB70-AA3,61,109 b. Undergoing a course of institutional or inpatient care from a provider or
10facility.
SB70-AA3,61,1211 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
12care, from a provider or facility.
SB70-AA3,61,1413 d. Pregnant and undergoing a course of treatment for the pregnancy from a
14provider or facility.
SB70-AA3,61,1615 e. Terminally ill and receiving treatment for the illness from a provider or
16facility.
SB70-AA3,61,1717 2. “Serious and complex condition” means any of the following:
SB70-AA3,61,2018 a. In the case of an acute illness, a condition that is serious enough to require
19specialized medical treatment to avoid the reasonable possibility of death or
20permanent harm.
SB70-AA3,61,2321 b. In the case of a chronic illness or condition, a condition that is
22life-threatening, degenerative, potentially disabling, or congenital and requires
23specialized medical care over a prolonged period.
SB70-AA3,62,624 (b) If an enrollee is a continuing care patient and is obtaining items or services
25from a participating provider or participating facility and the contract between the

1defined network plan, preferred provider plan, or self-insured governmental plan
2and the provider or facility is terminated because of a change in the terms of the
3participation of the provider or facility in the plan or the contract between the defined
4network plan, preferred provider plan, or self-insured governmental plan and the
5provider or facility is terminated, resulting in a loss of benefits provided under the
6plan, the plan shall do all of the following:
SB70-AA3,62,97 1. Notify each enrollee of the termination of the contract or benefits and of the
8right for the enrollee to elect to continue transitional care from the participating
9provider or participating facility under this subsection.
SB70-AA3,62,1110 2. Provide the enrollee an opportunity to notify the plan of the need for
11transitional care.
SB70-AA3,62,1812 3. Allow the enrollee to elect to continue to have the benefits provided under
13the plan under the same terms and conditions as would have applied to the item or
14service if the termination had not occurred for the course of treatment related to the
15enrollee's status as a continuing care patient beginning on the date on which the
16notice under subd. 1. is provided and ending 90 days after the date on which the
17notice under subd. 1. is provided or the date on which the enrollee is no longer a
18continuing care patient, whichever is earlier.
SB70-AA3,62,2119 (c) The provisions of s. 609.24 apply to a continuing care patient to the extent
20that s. 609.24 does not conflict with this subsection so as to limit the enrollee's rights
21under this subsection.
SB70-AA3,63,3 22(8) Rule making. The commissioner may promulgate any rules necessary to
23implement this section, including specifying the independent dispute resolution
24process under sub. (6). The commissioner may promulgate rules to modify the list
25of those items and services for which a provider may not balance bill under sub. (4)

1(c). In promulgating rules under this subsection, the commissioner may consider any
2rules promulgated by the federal department of health and human services pursuant
3to the federal No Suprises Act, 42 USC 300gg-111, et seq.
SB70-AA3,38 4Section 38. 609.24 (5) of the statutes is created to read:
SB70-AA3,63,75 609.24 (5) If an enrollee is a continuing care patient, as defined in s. 609.045
6(7) (a), and if any of the situations described under s. 609.045 (7) (b) (intro.) applies,
7all of the following apply to the enrollee's defined network plan:
SB70-AA3,63,108 (a) Subsection (1) (c) shall apply to any of the participating providers providing
9the enrollee's course of treatment under s. 609.045 (7), including the enrollee's
10primary care physician.
SB70-AA3,63,1311 (b) Subsection (1) (c) shall apply to lengthen the period in which benefits are
12provided under s. 609.045 (7) (b) 3., but shall not be applied to shorten the period in
13which benefits are provided under s. 609.045 (7) (b) 3.
SB70-AA3,63,1514 (c) Subsection (1) (d) shall not be applied in a manner that limits the enrollee's
15rights under s. 609.045 (7) (b) 3.
SB70-AA3,63,1816 (d) No plan may contract or arrange with a participating provider to provide
17notice of the termination of the participating provider's participation, pursuant to
18sub. (4).”.
SB70-AA3,63,19 19182. Page 374, line 11: after that line insert:
SB70-AA3,63,20 20 Section 39. 609.74 of the statutes is created to read:
SB70-AA3,63,22 21609.74 Coverage of infertility services. Defined network plans and
22preferred provider plans are subject to s. 632.895 (15m).
SB70-AA3,40 23Section 40. 632.895 (15m) of the statutes is created to read:
SB70-AA3,63,2424 632.895 (15m) Coverage of infertility services. (a) In this subsection:
SB70-AA3,64,6
11. “Diagnosis of and treatment for infertility” means any recommended
2procedure or medication to treat infertility at the direction of a physician that is
3consistent with established, published, or approved medical practices or professional
4guidelines from the American College of Obstetricians and Gynecologists, or its
5successor organization, or the American Society for Reproductive Medicine, or its
6successor organization.
SB70-AA3,64,87 2. “Infertility” means a disease, condition, or status characterized by any of the
8following:
SB70-AA3,64,139 a. The failure to establish a pregnancy or carry a pregnancy to a live birth after
10regular, unprotected sexual intercourse for, if the woman is under the age of 35, no
11longer than 12 months or, if the woman is 35 years of age or older, no longer than 6
12months, including any time during those 12 months or 6 months that the woman has
13a pregnancy that results in a miscarriage.
SB70-AA3,64,1514 b. An individual's inability to reproduce either as a single individual or with
15a partner without medical intervention.
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