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.
SB70-AA3,64,1716 c. A physician's findings based on a patient's medical, sexual, and reproductive
17history, age, physical findings, or diagnostic testing.
SB70-AA3,64,1918 3. “Self-insured health plan" means a self-insured health plan of the state or
19a county, city, village, town, or school district.
SB70-AA3,65,220 4. “Standard fertility preservation service” means a procedure that is
21consistent with established medical practices or professional guidelines published
22by the American Society for Reproductive Medicine or its successor organization, or
23the American Society of Clinical Oncology or its successor organization, for a person
24who has a medical condition or is expected to undergo medication therapy, surgery,

1radiation, chemotherapy, or other medical treatment that is recognized by medical
2professionals to cause a risk of impairment to fertility.
SB70-AA3,65,93 (b) Subject to pars. (c) to (e), every disability insurance policy and self-insured
4health plan that provides coverage for medical or hospital expenses shall cover
5diagnosis of and treatment for infertility and standard fertility preservation
6services. Coverage required under this paragraph includes at least 4 completed
7oocyte retrievals with unlimited embryo transfers, in accordance with the guidelines
8of the American Society for Reproductive Medicine or its successor organization, and
9single embryo transfer may be used when recommended and medically appropriate.
SB70-AA3,65,1110 (c) 1. A disability insurance policy or self-insured health plan may not do any
11of the following:
SB70-AA3,65,1412 a. Impose any exclusions, limitations, or other restrictions on coverage
13required under par. (b) based on a covered individual's participation in fertility
14services provided by or to a 3rd party.
SB70-AA3,65,1815 b. Impose any exclusion, limitation, or other restriction on coverage of
16medications that are required to be covered under par. (b) that are different from
17those imposed on any other prescription medications covered under the policy or
18plan.
SB70-AA3,65,2519 c. Impose any exclusion, limitation, cost-sharing requirement, benefit
20maximum, waiting period, or other restriction on coverage that is required under
21par. (b) of diagnosis of and treatment for infertility and standard fertility
22preservation services that is different from an exclusion, limitation, cost-sharing
23requirement, benefit maximum, waiting period or other restriction imposed on
24benefits for services that are covered by the policy or plan and that are not related
25to infertility.
SB70-AA3,66,4
12. A disability insurance policy or self-insured health plan shall provide
2coverage required under par. (b) to any covered individual under the policy or plan,
3including any covered spouse or nonspouse dependent, to the same extent as other
4pregnancy-related benefits covered under the policy or plan.
SB70-AA3,66,105 (d) The commissioner, after consulting with the department of health services
6on appropriate treatment for infertility, shall promulgate any rules necessary to
7implement this subsection. Before the promulgation of rules, disability insurance
8policies and self-insured health plans are considered to comply with the coverage
9requirements of par. (b) if the coverage conforms to the standards of the American
10Society for Reproductive Medicine.
SB70-AA3,66,1211 (e) This subsection does not apply to a disability insurance policy that is a
12health benefit plan described under s. 632.745 (11) (b).
SB70-AA3,9323 13Section 9323. Initial applicability; Insurance.
SB70-AA3,66,1414 (1u) Coverage of infertility services.
SB70-AA3,66,1815 (a) For policies and plans containing provisions inconsistent with these
16sections, the treatment of ss. 609.74 and 632.895 (15m) first applies to policy or plan
17years beginning on January 1 of the year following the year in which this paragraph
18takes effect, except as provided in pars. (b ) and (c).
SB70-AA3,66,2319 (b) For policies and plans that have a term greater than one year and contain
20provisions inconsistent with these sections, the treatment of ss. 609.74 and 632.895
21(15m) first applies to policy or plan years beginning on January 1 of the year
22following the year in which the policy or plan is extended, modified, or renewed,
23whichever is later.
SB70-AA3,67,324 (c) For policies and plans that are affected by a collective bargaining agreement
25containing provisions inconsistent with these sections, the treatment of ss. 609.74

1and 632.895 (15m) first applies to policy or plan years beginning on the effective date
2of this paragraph or on the day on which the collective bargaining agreement is
3entered into, extended, modified, or renewed, whichever is later.
SB70-AA3,9423 4Section 9423. Effective dates; Insurance.
SB70-AA3,67,75 (1v) Coverage of infertility services. The treatment of ss. 609.74 and 632.895
6(15m) and Section 9323 (1u) of this act take effect on the first day of the 4th month
7beginning after publication.”.
SB70-AA3,67,8 8183. Page 374, line 11: after that line insert:
SB70-AA3,67,9 9 Section 41 . 609.713 of the statutes is created to read:
SB70-AA3,67,12 10609.713 Qualified treatment trainee coverage. Limited service health
11organizations, preferred provider plans, and defined network plans are subject to s.
12632.87 (7).
SB70-AA3,42 13Section 42 . 632.87 (7) of the statutes is created to read:
SB70-AA3,67,1414 632.87 (7) (a) In this subsection:
SB70-AA3,67,1515 1. “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).
SB70-AA3,67,1616 2. “Qualified treatment trainee” has the meaning given in s. DHS 35.03 (17m).
SB70-AA3,67,2117 (b) No policy, plan, or contract may exclude coverage for mental health or
18behavioral health treatment or services provided by a qualified treatment trainee
19within the scope of the qualified treatment trainee's education and training if the
20policy, plan, or contract covers the mental health or behavioral health treatment or
21services when provided by another health care provider.
SB70-AA3,9323 22Section 9323. Initial applicability; Insurance.
SB70-AA3,67,2323 (1u) Qualified treatment trainee coverage.
SB70-AA3,68,4
1(a) For policies and plans containing provisions inconsistent with this section,
2the treatment of s. 632.87 (7) first applies to policy or plan years beginning on
3January 1 of the year following the year in which this paragraph takes effect, except
4as provided in par. (b).
SB70-AA3,68,95 (b) For policies and plans that are affected by a collective bargaining agreement
6containing provisions inconsistent with this section, the treatment of s. 632.87 (7)
7first applies to policy or plan years beginning on the effective date of this paragraph
8or on the day on which the collective bargaining agreement is entered into, extended,
9modified, or renewed, whichever is later.
SB70-AA3,9423 10Section 9423. Effective dates; Insurance.
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