SB434: Bill Text

2025 - 2026 LEGISLATURE

LRB-4515/1

JPC:cjs&emw

2025 SENATE BILL 434

September 29, 2025 - Introduced by Senators Cabral-Guevara, Jacque and Nass, cosponsored by Representatives Dittrich, Behnke, Goeben, Kreibich, Maxey, Mursau and Palmeri. Referred to Committee on Insurance, Housing, Rural Issues and Forestry.

SB434,1,4 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 and 632.848 of the statutes; relating to: transparency and regulation of prior authorization requirements under health insurance plans.

Analysis by the Legislative Reference Bureau

This bill establishes several disclosure and regulatory requirements for prior authorizations for health care services under health insurance policies and plans. Under the bill, “prior authorization” is defined to mean the process by which utilization review entities determine the medical necessity or medical appropriateness of an otherwise covered health care service prior to the rendering of the health care service.

First, this bill requires that utilization review entities ensure that all adverse determinations are made by a physician, physician assistant, or advanced practice registered nurse who may issue prescription orders and that the physician, physician assistant, or advanced practice registered nurse makes the adverse determination under the clinical direction of one of the utilization review entity’s medical directors who is responsible for the provision of health care services provided to enrollees in this state. An adverse determination is a decision by a utilization review entity that health care services provided or proposed to be provided to an enrollee are not medically necessary, or are experimental or investigational, and that benefit coverage is therefore denied, reduced, or terminated.

Further, this bill provides that a utilization review entity must render an authorization or adverse determination within 72 hours of obtaining all necessary information to render the authorization or adverse determination. If the health care service requiring prior authorization is an urgent health care service, the bill instead requires that a utilization review entity render an authorization or adverse determination for the urgent health care service not later than 24 hours after receiving all necessary information to render the authorization or adverse determination. This bill provides that authorizations are valid for no less than one year from the date that a health care provider receives the authorization and that authorizations must remain effective regardless of any changes in form, dosage, or method of administration for a prescription drug prescribed by the health care provider and regardless of any changes in frequency, extent, or duration for a health care service provided by the health care provider. This bill further provides that an authorization for a health care service that is a treatment of a chronic or long-term care condition must remain valid for the duration of the treatment.

This bill provides that if an enrollee begins receiving health care services under a new health insurance plan, a utilization review entity must, upon receipt of sufficient information documenting a previous authorization rendered to the enrollee from a previous utilization review entity, accept the authorization rendered to the enrollee by the previous utilization review entity for at least 90 days of the enrollee’s coverage under the new health insurance plan. During this grace period, a utilization review entity may perform its own prior authorization. If there is a change in coverage of, or utilization review criteria for, a previously authorized health care service, the change in coverage or utilization review criteria may not affect an enrollee who was rendered an authorization before the effective date of the change for the remainder of the enrollee’s plan year.

Finally, this bill prohibits a utilization review entity from denying payment for a health care service that has received authorization unless the health care provider that performed the health care service knowingly and materially misrepresented the health care service to the utilization review entity with the intent to deceive and to obtain an unlawful payment or the enrollee was not eligible for coverage on the day that the health care service was performed.

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:

SB434,1 Section 1. 40.51 (8) of the statutes is amended to read:

SB434,3,4 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.

SB434,2 Section 2. 40.51 (8m) of the statutes is amended to read:

SB434,3,9 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).

SB434,3 Section 3. 66.0137 (4) of the statutes is amended to read:

SB434,3,17 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).

SB434,4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

SB434,3,22 120.13 (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).

SB434,5 Section 5. 185.983 (1) (intro.) of the statutes is amended to read:

SB434,4,7 185.983 (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:

SB434,6 Section 6. 609.815 of the statutes is created to read:

SB434,4,11 609.815 Prior authorization regulation and transparency. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.848.

SB434,7 Section 7. 632.848 of the statutes is created to read:

SB434,4,14 632.848 Prior authorization regulation and transparency. (1) Definitions. In this section:

SB434,4,18 (a) “Adverse determination” means a decision by a utilization review entity that health care services provided or proposed to be provided to an enrollee are not medically necessary, or are experimental or investigational, and that benefit coverage is therefore denied, reduced, or terminated.

SB434,4,22 (b) “Authorization” means a determination made by a utilization review entity that a health care service has been reviewed and, based on the information provided, satisfies the utilization review entity’s requirements for medical necessity and appropriateness and that payment will be made for the health care service.

SB434,4,23 (c) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB434,5,3 (d) “Health care service” means a health care procedure, treatment, or service that is provided by a facility licensed in this state or that is provided by a health care provider within the scope of his or her practice. “Health care service” includes the provision of pharmaceutical products or durable medical equipment.

SB434,5,4 (e) “Physician” has the meaning given in s. 448.01 (5).

SB434,5,7 (f) “Physician assistant” means a person who is licensed as a physician assistant under subch. IX of ch. 448 or who holds a compact privilege under subch. XIII of ch. 448.

SB434,5,14 (g) “Prior authorization” means the process by which utilization review entities determine the medical necessity or medical appropriateness of an otherwise covered health care service prior to the rendering of the health care service. “Prior authorization” includes any health benefit plan's, self-insured health plan's, or utilization review entity's requirement that an enrollee or health care provider notify the health benefit plan or utilization review entity prior to receiving or providing a health care service.

SB434,5,17 (h) “Enrollee” means an individual eligible to receive health care benefits under a health benefit plan or a self-ensured health plan. “Enrollee” includes an enrollee’s legally authorized representative.

SB434,5,18 (i) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB434,5,22 (j) 1. “Urgent health care service” means a health care service that, in the opinion of a physician with knowledge of the enrollee's medical condition, must be provided sooner than the deadline for prior authorization under sub. (3) to avoid any of the following results for the enrollee:

SB434,5,24 a. Serious jeopardy to life, health, or the ability to regain maximum bodily function.

SB434,6,2 b. Severe pain that cannot be adequately managed without the care or treatment that is the subject of the prior authorization.

SB434,6,4 2. “Urgent health care service” includes mental and behavioral health services.

SB434,6,5 3. “Urgent health care service” does not include emergency services.

SB434,6,7 (k) “Utilization review entity” means any person that performs prior authorizations for any of the following:

SB434,6,8 1. An insurer that writes health care liability insurance in this state.

SB434,6,11 2. A preferred provider plan, as defined in s. s. 609.01 (4), a defined network plan, as defined ins. 609.01 (1b), or a limited service health organization, as defined in s. 609.01 (3).

SB434,6,14 3. Any other person that provides, offers to provide, or administers hospital, outpatient, medical, prescription drug, or other health benefits to an individual in this state.

SB434,6,17 (2) Personnel qualified to make adverse determinations. A utilization review entity shall ensure that all adverse determinations are made by a health care provider who satisfies all of the following criteria:

SB434,6,20 (a) The health care provider is a physician, a physician assistant, or an advanced practice registered nurse who may issue prescription orders under s. 441.09 (2).

SB434,7,2 (b) The health care provider makes the adverse determination under the clinical direction of one of the utilization review entity’s medical directors who is responsible for the provision of health care services provided to enrollees in this state. All of the utilization review entity’s medical directors shall be physicians licensed in this state.

SB434,7,10 (3) Obligations of utilization review entity in nonurgent circumstances. Subject to sub. (4), a utilization review entity shall render an authorization or adverse determination, and notify the enrollee and the enrollee’s health care provider of the authorization or adverse determination, within 72 hours of obtaining all necessary information to render the authorization or adverse determination. For purposes of this subsection, “necessary information” includes the results of any face-to-face clinical evaluation or second opinion that may be required.

SB434,7,16 (4) Obligations of utilization review entity in urgent circumstances. A utilization review entity shall render an authorization or adverse determination concerning an urgent health care service, and notify the enrollee and the enrollee’s health care provider of the authorization or adverse determination, not later than 24 hours after receiving all necessary information to render the authorization or adverse determination.

SB434,7,22 (5) Duration of authorization. Subject to sub. (6), an authorization shall be valid for no less than one year from the date that a health care provider receives the authorization and the authorization shall remain effective regardless of any changes in form, dosage, or method of administration for a prescription drug prescribed by the health care provider and regardless of any changes in frequency, extent, or duration for a health care service provided by the health care provider.

SB434,8,2 (6) Duration of authorization for treatment of chronic or long-term care conditions. (a) In this subsection, “chronic or long-term care condition” means a medical condition that has persisted for at least one year and continues to persist after reasonable efforts have been made to relieve or cure its cause.

SB434,8,6 (b) An authorization for a health care service that is a treatment of a chronic or long-term care condition shall remain valid for the duration of the treatment and the utilization review entity may not require the enrollee to obtain an authorization again for the treatment.