SB70,1566,2522 (c) A conflict of interest under this subsection shall be disclosed no later than
235 days after the conflict is identified, except that, if the conflict is identified within
245 days of an open meeting of the board, the conflict shall be disclosed prior to the
25meeting.
SB70,1567,4
1(d) The board shall disclose a conflict of interest under this subsection on the
2board's website unless the chair of the board recuses the member from a final
3decision relating to a review of the prescription drug product. The disclosure shall
4include the type, nature, and magnitude of the interests of the member involved.
SB70,1567,75 (e) A member of the board or a 3rd-party contractor may not accept any gift or
6donation of services or property that indicates a potential conflict of interest or has
7the appearance of biasing the work of the board.
SB70,3045 8Section 3045. 601.79 of the statutes is created to read:
SB70,1567,10 9601.79 Drug cost affordability review. (1) Identification of drugs. The
10board shall identify prescription drug products that are any of the following:
SB70,1567,1411 (a) A brand name drug or biologic that, as adjusted annually to reflect
12adjustments to the U.S. consumer price index for all urban consumers, U.S. city
13average, as determined by the U.S. department of labor, has a launch wholesale
14acquisition cost of at least $30,000 per year or course of treatment.
SB70,1567,1815 (b) A brand name drug or biologic that, as adjusted annually to reflect
16adjustments to the U.S. consumer price index for all urban consumers, U.S. city
17average, as determined by the U.S. department of labor, has a wholesale acquisition
18cost that has increased at least $3,000 during a 12-month period.
SB70,1567,2119 (c) A biosimilar that has a launch wholesale acquisition cost that is not at least
2015 percent lower than the referenced brand biologic at the time the biosimilar is
21launched.
SB70,1567,2522 (d) A generic drug that has a wholesale acquisition cost, as adjusted annually
23to reflect adjustments to the U.S. consumer price index for all urban consumers, U.S.
24city average, as determined by the U.S. department of labor, that meets all of the
25following conditions:
SB70,1568,6
11. Is at least $100 for a supply lasting a patient for a period of 30 consecutive
2days based on the recommended dosage approved for labeling by the federal food and
3drug administration, a supply lasting a patient for a period of fewer than 30 days
4based on the recommended dosage approved for labeling by the federal food and drug
5administration, or one unit of the drug if the labeling approved by the federal food
6and drug administration does not recommend a finite dosage.
SB70,1568,97 2. Increased by at least 200 percent during the preceding 12-month period, as
8determined by the difference between the resulting wholesale acquisition cost and
9the average of the wholesale acquisition cost reported over the preceding 12 months.
SB70,1568,1210 (e) Other prescription drug products, including drugs to address public health
11emergencies, that may create affordability challenges for the health care system and
12patients in this state.
SB70,1568,17 13(2) Affordability review. (a) After identifying prescription drug products
14under sub. (1), the board shall determine whether to conduct an affordability review
15for each identified prescription drug product by seeking stakeholder input about the
16prescription drug product and considering the average patient cost share of the
17prescription drug product.
SB70,1568,2318 (b) The information used to conduct an affordability review under par. (a) may
19include any document and research related to the manufacturer's selection of the
20introductory price or price increase of the prescription drug product, including life
21cycle management, net average price in this state, market competition and context,
22projected revenue, and the estimated value or cost-effectiveness of the prescription
23drug product.
SB70,1569,3
1(c) The failure of a manufacturer to provide the board with information for an
2affordability review under par. (b) does not affect the authority of the board to
3conduct the review.
SB70,1569,11 4(3) Affordability challenge. When conducting an affordability review of a
5prescription drug product under sub. (2), the board shall determine whether use of
6the prescription drug product that is fully consistent with the labeling approved by
7the federal food and drug administration or standard medical practice has led or will
8lead to an affordability challenge for the health care system in this state, including
9high out-of-pocket costs for patients. To the extent practicable, in determining
10whether a prescription drug product has led or will lead to an affordability challenge,
11the board shall consider all of the following factors:
SB70,1569,1312 (a) The wholesale acquisition cost for the prescription drug product sold in this
13state.
SB70,1569,1714 (b) The average monetary price concession, discount, or rebate the
15manufacturer provides, or is expected to provide, to health plans in this state as
16reported by manufacturers and health plans, expressed as a percent of the wholesale
17acquisition cost for the prescription drug product under review.
SB70,1569,2118 (c) The total amount of the price concessions, discounts, and rebates the
19manufacturer provides to each pharmacy benefit manager for the prescription drug
20product under review, as reported by the manufacturer and pharmacy benefit
21manager and expressed as a percent of the wholesale acquisition cost.
SB70,1569,2322 (d) The price at which therapeutic alternatives to the prescription drug product
23have been sold in this state.
SB70,1570,3
1(e) The average monetary concession, discount, or rebate the manufacturer
2provides or is expected to provide to health plan payors and pharmacy benefit
3managers in this state for therapeutic alternatives to the prescription drug product.
SB70,1570,64 (f) The costs to health plans based on patient access consistent with labeled
5indications by the federal food and drug administration and recognized standard
6medical practice.
SB70,1570,87 (g) The impact on patient access resulting from the cost of the prescription drug
8product relative to insurance benefit design.
SB70,1570,109 (h) The current or expected dollar value of drug-specific patient access
10programs that are supported by the manufacturer.
SB70,1570,1311 (i) The relative financial impacts to health, medical, or social services costs that
12can be quantified and compared to baseline effects of existing therapeutic
13alternatives to the prescription drug product.
SB70,1570,1514 (j) The average patient copay or other cost sharing for the prescription drug
15product in this state.
SB70,1570,1616 (k) Any information a manufacturer chooses to provide.
SB70,1570,1717 (L) Any other factors as determined by the board by rule.
SB70,1570,21 18(4) Upper payment limit. (a) If the board determines under sub. (3) that use
19of a prescription drug product has led or will lead to an affordability challenge, the
20board shall establish an upper payment limit for the prescription drug product after
21considering all of the following:
SB70,1570,2222 1. The cost of administering the drug.
SB70,1570,2323 2. The cost of delivering the drug to consumers.
SB70,1570,2424 3. Other relevant administrative costs related to the drug.
SB70,1571,6
1(b) For a prescription drug product identified in sub. (1) (b) or (d) 2., the board
2shall solicit information from the manufacturer regarding the price increase. To the
3extent that the price increase is not a result of the need for increased manufacturing
4capacity or other effort to improve patient access during a public health emergency,
5the board shall establish an upper payment limit under par. (a) that is equal to the
6cost to consumers prior to the price increase.
SB70,1571,107 (c) 1. The upper payment limit established under this subsection shall apply
8to all purchases and payor reimbursements of the prescription drug product
9dispensed or administered to individuals in this state in person, by mail, or by other
10means.
SB70,1571,2111 2. Notwithstanding subd. 1., while state-sponsored and state-regulated
12health plans and health programs shall limit drug reimbursements and drug
13payment to no more than the upper payment limit established under this subsection,
14a plan subject to the Employee Retirement Income Security Act of 1974 or Part D of
15Medicare under 42 USC 1395w-101 et seq. may choose to reimburse more than the
16upper payment limit. A provider who dispenses and administers a prescription drug
17product in this state to an individual in this state may not bill a payor more than the
18upper payment limit to the patient regardless of whether a plan subject to the
19Employee Retirement Income Security Act of 1974 or Part D of Medicare under 42
20USC 1395w-101
et seq. chooses to reimburse the provider above the upper payment
21limit.
SB70,1571,23 22(5) Public inspection. Information submitted to the board under this section
23shall be open to public inspection only as provided under ss. 19.31 to 19.39.
SB70,1572,2 24(6) No prohibition on marketing. Nothing in this section may be construed to
25prevent a manufacturer from marketing a prescription drug product approved by the

1federal food and drug administration while the prescription drug product is under
2review by the board.
SB70,1572,7 3(7) Appeals. A person aggrieved by a decision of the board may request an
4appeal of the decision no later than 30 days after the board makes the determination.
5The board shall hear the appeal and make a final decision no later than 60 days after
6the appeal is requested. A person aggrieved by a final decision of the board may
7petition for judicial review in a court of competent jurisdiction.
SB70,3046 8Section 3046 . 601.83 (1) (a) of the statutes is amended to read:
SB70,1572,219 601.83 (1) (a) The commissioner shall administer a state-based reinsurance
10program known as the healthcare stability plan in accordance with the specific terms
11and conditions approved by the federal department of health and human services
12dated July 29, 2018. Before December 31, 2023, the commissioner may not request
13from the federal department of health and human services a modification,
14suspension, withdrawal, or termination of the waiver under 42 USC 18052 under
15which the healthcare stability plan under this subchapter operates unless
16legislation has been enacted specifically directing the modification, suspension,
17withdrawal, or termination. Before December 31, 2023, the commissioner may
18request renewal, without substantive change, of the waiver under 42 USC 18052
19under which the health care stability plan operates in accordance with s. 20.940 (4)
20unless legislation has been enacted that is contrary to such a renewal request. The
21commissioner shall comply with applicable timing in and requirements of s. 20.940.
SB70,3047 22Section 3047. 601.83 (1) (h) of the statutes is renumbered 601.83 (1) (h) (intro.)
23and amended to read:
SB70,1573,424 601.83 (1) (h) (intro.) In 2019 and in each subsequent year Unless the joint
25committee on finance under s. 13.10 increases the amount upon request by the

1commissioner
, the commissioner may expend no more than $200,000,000 the
2following amounts
from all revenue sources for the healthcare stability plan under
3this section, unless the joint committee on finance under s. 13.10 has increased this
4amount upon request by the commissioner.
:
SB70,1573,8 5(he) The commissioner shall ensure that sufficient funds are available for the
6healthcare stability plan under this section to operate as described in the approval
7of the federal department of health and human services dated July 29, 2018, and in
8any waiver extension approvals
.
SB70,3048 9Section 3048. 601.83 (1) (h) 1. and 3. of the statutes are created to read:
SB70,1573,1010 601.83 (1) (h) 1. In 2019, 2020, and 2021, $200,000,000.
SB70,1573,1911 3. In 2025 and in each year thereafter, the maximum expenditure amount for
12the previous year, adjusted to reflect the percentage increase, if any, in the consumer
13price index for all urban consumers, U.S. city average, for the medical care group, as
14determined by the U.S. department of labor, for the 12-month period ending on
15December 31 of the year before the year in which the amount is determined. The
16commissioner shall determine the annual adjustment amount for a particular year
17in January of the previous year. The commissioner shall publish the new maximum
18expenditure amount under this subdivision each year in the Wisconsin
19Administrative Register.
SB70,3049 20Section 3049. 601.83 (1) (hm) of the statutes is renumbered 601.83 (1) (h) 2.
21and amended to read:
SB70,1573,2422 601.83 (1) (h) 2. Notwithstanding par. (h), in In 2022 and in each year
23thereafter, the commissioner may expend from all revenue sources
, 2023, and 2024,
24$230,000,000 or less for the healthcare stability plan under this section.
SB70,3050 25Section 3050 . 609.045 of the statutes is created to read:
SB70,1574,2
1609.045 Balance billing; emergency medical services. (1) Definitions.
2In this section:
SB70,1574,33 (a) “Emergency medical condition” means all of the following:
SB70,1574,74 1. A medical condition, including a mental health condition or substance use
5disorder condition, manifesting itself by acute symptoms of sufficient severity,
6including severe pain, such that the absence of immediate medical attention could
7reasonably be expected to result in any of the following:
SB70,1574,98 a. Placing the health of the individual or, with respect to a pregnant woman,
9the health of the woman or her unborn child, in serious jeopardy.
SB70,1574,1010 b. Serious impairment of bodily function.
SB70,1574,1111 c. Serious dysfunction of any bodily organ or part.
SB70,1574,1512 2. With respect to a pregnant woman who is having contractions, a medical
13condition for which there is inadequate time to safely transfer the pregnant woman
14to another hospital before delivery or for which the transfer may pose a threat to the
15health or safety of the pregnant woman or the unborn child.
SB70,1574,1816 (b) “Emergency medical services,” with respect to an emergency medical
17condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a)
18(3) (C).
SB70,1574,2019 (c) “Independent freestanding emergency department" has the meaning given
20in 42 USC 300gg-111 (a) (3) (D).
SB70,1574,2221 (d) “Out-of-network rate” has the meaning given by the commissioner by rule
22or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).
SB70,1575,223 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
24preferred provider plan, as defined in s. 609.01 (4), that has a network of

1participating providers and imposes on enrollees different requirements for using
2providers that are not participating providers.
SB70,1575,43 (f) “Recognized amount” has the meaning given by the commissioner by rule
4or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).
SB70,1575,85 (g) “Self-insured governmental plan” means a self-insured health plan of the
6state or a county, city, village, town, or school district that has a network of
7participating providers and imposes on enrollees in the self-insured health plan
8different requirements for using providers that are not participating providers.
SB70,1575,119 (h) “Terminated” means the expiration or nonrenewal of a contract.
10“Terminated” does not include a termination of a contract for failure to meet
11applicable quality standards or for fraud.
SB70,1575,16 12(2) Emergency medical services. A defined network plan, preferred provider
13plan, or self-insured governmental plan that covers any benefits or services provided
14in an emergency department of a hospital or emergency medical services provided
15in an independent freestanding emergency department shall cover emergency
16medical services in accordance with all of the following:
SB70,1575,1717 (a) The plan may not require a prior authorization determination.
SB70,1575,2018 (b) The plan may not deny coverage on the basis of whether or not the health
19care provider providing the services is a participating provider or participating
20emergency facility.
SB70,1575,2321 (c) If the emergency medical services are provided to an enrollee by a provider
22or in a facility that is not a participating provider or participating facility, the plan
23complies with all of the following:
SB70,1576,224 1. The emergency medical services are covered without imposing on an enrollee
25a requirement for prior authorization or any coverage limitation that is more

1restrictive than requirements or limitations that apply to emergency medical
2services provided by participating providers or in participating facilities.
SB70,1576,63 2. Any cost-sharing requirement imposed on an enrollee for the emergency
4medical services is no greater than the requirements that would apply if the
5emergency medical services were provided by a participating provider or in a
6participating facility.
SB70,1576,117 3. Any cost-sharing amount imposed on an enrollee for the emergency medical
8services is calculated as if the total amount that would have been charged for the
9emergency medical services if provided by a participating provider or in a
10participating facility is equal to the recognized amount for such services, plan or
11coverage, and year.
SB70,1576,1212 4. The plan does all of the following:
SB70,1576,1513 a. No later than 30 days after the participating provider or participating facility
14transmits to the plan the bill for emergency medical services, sends to the provider
15or facility an initial payment or a notice of denial of payment.
SB70,1576,1816 b. Pays to the participating provider or participating facility a total amount
17that, incorporating any initial payment under subd. 4. a., is equal to the amount by
18which the out-of-network rate exceeds the cost-sharing amount.
SB70,1576,2319 5. The plan counts any cost-sharing payment made by the enrollee for the
20emergency medical services toward any in-network deductible or out-of-pocket
21maximum applied by the plan in the same manner as if the cost-sharing payment
22was made for emergency medical services provided by a participating provider or in
23a participating facility.
SB70,1577,4 24(3) Nonparticipating provider in participating facility. For items or services
25other than emergency medical services that are provided to an enrollee of a defined

1network plan, preferred provider plan, or self-insured governmental plan by a
2provider who is not a participating provider but who is providing services at a
3participating facility, the plan shall provide coverage for the item or service in
4accordance with all of the following:
SB70,1577,75 (a) The plan may not impose on an enrollee a cost-sharing requirement for the
6item or service that is greater than the cost-sharing requirement that would have
7been imposed if the item or service was provided by a participating provider.
SB70,1577,118 (b) Any cost-sharing amount imposed on an enrollee for the item or service is
9calculated as if the total amount that would have been charged for the item or service
10if provided by a participating provider is equal to the recognized amount for such
11item or service, plan or coverage, and year.
SB70,1577,1312 (c) No later than 30 days after the provider transmits the bill for services, the
13plan shall send to the provider an initial payment or a notice of denial of payment.
SB70,1577,1714 (d) The plan shall make a total payment directly to the provider who provided
15the item or service to the enrollee that, added to any initial payment described under
16par. (c), is equal to the amount by which the out-of-network rate for the item or
17service exceeds the cost-sharing amount.
SB70,1577,2118 (e) The plan counts any cost-sharing payment made by the enrollee for the item
19or service toward any in-network deductible or out-of-pocket maximum applied by
20the plan in the same manner as if the cost-sharing payment was made for the item
21or service when provided by a participating provider.
SB70,1578,2 22(4) Charging for services by nonparticipating provider; notice and consent.
23(a) Except as provided in par. (c), a provider of an item or service who is entitled to
24payment under sub. (3) may not bill or hold liable an enrollee for any amount for the
25item or service that is more than the cost-sharing amount calculated under sub. (3)

1(b) for the item or service unless the nonparticipating provider provides notice and
2obtains consent in accordance with all of the following:
SB70,1578,53 1. The notice states that the provider is not a participating provider in the
4enrollee's defined network plan, preferred provider plan, or self-insured
5governmental plan.
SB70,1578,96 2. The notice provides a good faith estimate of the amount that the
7nonparticipating provider may charge the enrollee for the item or service involved,
8including notification that the estimate does not constitute a contract with respect
9to the charges estimated for the item or service.
SB70,1578,1210 3. The notice includes a list of the participating providers at the participating
11facility who would be able to provide the item or service and notification that the
12enrollee may be referred to one of those participating providers.
SB70,1578,1513 4. The notice includes information about whether or not prior authorization or
14other care management limitations may be required before receiving an item or
15service at the participating facility.
SB70,1578,1716 5. The notice clearly states that consent is optional and that the patient may
17elect to seek care from an in-network provider.
SB70,1578,1818 6. The notice is worded in plain language.
SB70,1578,2019 7. The notice is available in languages other than English. The commissioner
20shall identify languages for which the notice should be available.
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