SB1163: Bill Text

2025 - 2026 LEGISLATURE

LRB-6501/1

EKL:cdc

2025 SENATE BILL 1163

March 19, 2026 - Introduced by Senators Roys, Larson, Ratcliff and Smith, cosponsored by Representatives Prado, Clancy, Madison, McCarville, Sinicki, Tenorio and Subeck. Referred to Committee on Insurance, Housing, Rural Issues and Forestry.

SB1163,1,4 An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g) and 185.983 (1) (intro.); to create 609.815, 628.42 and 632.848 of the statutes; relating to: prior authorization transparency, exemptions from prior authorization requirements, and granting rule-making authority.

Analysis by the Legislative Reference Bureau

This bill imposes several requirements on the use of prior authorization by health care plans. Under the bill, a health care plan must maintain a list of services for which prior authorization is required and publish the list on a website that is accessible to the general public without requiring users to create an account or input credentials. Each plan must also post on its website, or the website of a contracted utilization review organization, its current prior authorization requirements and restrictions in an accessible and conspicuous manner for enrollees and providers.

The bill provides that if a health care plan intends to impose or amend a prior authorization requirement or restriction, the plan must provide at least 60 days advanced written notice to providers. Further, a health care plan may not implement a new or amended prior authorization requirement or restriction unless the plan, or a contracted utilization review organization, has updated its website to reflect the change.

The bill also requires that clinical review criteria that a health care plan uses for prior authorization decisions meet certain conditions, including be based on nationally recognized, generally accepted standards, be developed in accordance with the current standards of a national medical accreditation entity, and ensure quality of care and access to needed health care services.

Further, the bill prohibits a health care plan from denying a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided. The bill also prohibits plans and contracted utilization review organizations from deeming supplies or services as incidental and from denying a claim for supplies or services if a provided health care service associated with the supplies or services receives, or does not require, prior authorization.

Finally, the bill allows the commissioner of insurance to establish, by rule, that a health insurance policy or self-insured health plan must exempt health care providers from obtaining prior authorization for a health care item or service for a period of time determined by the commissioner if, in the most recent evaluation period determined by the commissioner, the policy or plan has approved or would have approved not less than a specified proportion of prior authorization requests submitted by the provider for the item or service. Under the bill, the commissioner may specify the health care items or services subject to the exemption and how providers can obtain an exemption, including a process for automatic evaluation.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB1163,1 Section 1. 40.51 (8) of the statutes is amended to read:

SB1163,2,6 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.848, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.

SB1163,2 Section 2. 40.51 (8m) of the statutes is amended to read:

SB1163,3,2 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.848, 632.85, 632.853, 632.855, 632.861, 632.867, 632.885, 632.89, and 632.895 (11) to (17).

SB1163,3 Section 3. 66.0137 (4) of the statutes is amended to read:

SB1163,3,10 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.848, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB1163,4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

SB1163,3,15 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.848, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB1163,5 Section 5. 185.983 (1) (intro.) of the statutes is amended to read:

SB1163,3,24 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.848, 632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (2) to (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

SB1163,6 Section 6. 609.815 of the statutes is created to read:

SB1163,4,4 609.815 Exemption from prior authorization requirements. Limited service health organizations, preferred provider plans, and defined network plans are subject to any rules promulgated by the commissioner under s. 632.848.

SB1163,7 Section 7. 628.42 of the statutes is created to read:

SB1163,4,7 628.42 Disclosure and review of prior authorization requirements. (1) In this section:

SB1163,4,8 (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

SB1163,4,11 (b) 1. “Prior authorization” means the process by which a health care plan or a contracted utilization review organization determines the medical necessity and medical appropriateness of otherwise covered health care services.

SB1163,4,14 2. “Prior authorization” includes any requirement that an enrollee or provider notify the health care plan or a contracted utilization review organization before, at the time of, or concurrent to providing a health care service.

SB1163,4,15 (b) “Provider” has the meaning given in s. 628.36 (2) (a) 2.

SB1163,4,18 (2) (a) A health care plan shall maintain a complete list of services for which prior authorization is required, including services where prior authorization is performed by an entity under contract with the health care plan.

SB1163,4,21 (b) A health care plan shall publish the list under par. (a) on its website. The list shall be accessible by members of the general public without requiring the creation of an account or the entry of any credentials or personal information.

SB1163,4,23 (c) The list under par. (a) is not required to contain any clinical review criteria applicable to the services.

SB1163,5,7 (3) (a) A health care plan shall make any current prior authorization requirements and restrictions along with the clinical review criteria applicable to those requirements or restrictions accessible and conspicuously posted on its website to enrollees and providers. Content published by a 3rd party and licensed for use by a health care plan or a contracted utilization review organization may satisfy this subsection if it is available to access through the website of the health care plan or the contracted utilization review organization as long as the website does not unreasonably restrict access.

SB1163,5,10 (b) The prior authorization requirements and restrictions under par. (a) shall be described in detail and shall be written in easily understandable, plain language.

SB1163,5,13 (c) The prior authorization requirements and restrictions under par. (a) shall indicate all of the following for each service subject to a prior authorization requirement or restriction:

SB1163,5,15 1. When the requirement or restriction began for policies issued or delivered in this state, including effective dates and any termination dates.

SB1163,5,17 2. The date that the requirement or restriction was listed on the website of the health care plan or a contracted utilization review organization.

SB1163,5,18 3. The date that the requirement or restriction was removed in this state.

SB1163,5,20 4. A method to access a standardized electronic prior authorization request transaction process.

SB1163,5,22 (4) Any clinical review criteria on which a prior authorization requirement or restriction is based shall satisfy all of the following:

SB1163,5,24 (a) The criteria are based on nationally recognized, generally accepted standards except where provided by law.

SB1163,6,2 (b) The criteria are developed in accordance with the current standards of a national medical accreditation entity.

SB1163,6,4 (c) The criteria ensure quality of care and access to needed health care services.

SB1163,6,5 (d) The criteria are evidence-based.

SB1163,6,7 (e) The criteria are sufficiently flexible to allow deviations from current standards when justified.

SB1163,6,9 (f) The criteria are evaluated and updated when necessary and no less frequently than once every year.

SB1163,6,12 (5) No health care plan may deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided.

SB1163,6,17 (6) A health care plan or contracted utilization review organization may not deem supplies or services as incidental or deny a claim for supplies or services if a provided health care service associated with the supplies or services receives prior authorization or if a provided health care service associated with the supplies or services does not require prior authorization.

SB1163,7,5 (7) If a health care plan intends to impose a new prior authorization requirement or restriction or intends to amend a prior authorization requirement or restriction, the health care plan shall provide all providers contracted with the health care plan advanced written notice of the new or amended requirement or restriction no less than 60 days before the new or amended requirement or restriction is implemented. The advanced written notice may be provided in an electronic format if the provider has agreed in advance to receive the notices electronically. No health care plan may implement a new or amended prior authorization requirement or restriction unless the health care plan or a contracted utilization review organization has updated the information posted on its website required under sub. (3) to reflect the new or amended prior authorization requirement or restriction.

SB1163,8 Section 8. 632.848 of the statutes is created to read:

SB1163,7,8 632.848 Exemption from prior authorization requirements. (1) In this section: