AB768-ASA1,438,7
4609.34 Clinical decision-making; medical director. A managed care plan
5shall appoint a physician as medical director. The medical director shall be
6responsible for clinical protocols, quality assurance activities and utilization
7management policies of the plan.
AB768-ASA1,438,11
9609.36 Data systems and confidentiality. (1) Information and data
10reporting. (a) A managed care plan shall provide to the commissioner information
11related to all of the following:
AB768-ASA1,438,1212
1. The structure of the plan.
AB768-ASA1,438,1313
2. Health care benefits and exclusions.
AB768-ASA1,438,1414
3. Cost-sharing requirements.
AB768-ASA1,438,1515
4. Participating providers.
AB768-ASA1,438,1716
(b) Subject to sub. (2), the information and data reported under par. (a) shall
17be open to public inspection under ss. 19.31 to 19.39.
AB768-ASA1,438,20
18(2) Confidentiality. A managed care plan shall establish written policies and
19procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical
20records and enrollee communications to ensure confidentiality.
AB768-ASA1,438,25
22609.38 Oversight. The office shall perform examinations of insurers that
23issue managed care plans consistent with ss. 601.43 and 601.44. The commissioner
24shall by rule develop standards for managed care plans for compliance with the
25requirements under this chapter.
AB768-ASA1,439,102
609.65
(1) (intro.) If an
enrolled participant of a health maintenance
3organization, enrollee of a limited service health organization
or, preferred provider
4plan
or managed care plan is examined, evaluated or treated for a nervous or mental
5disorder pursuant to an emergency detention under s. 51.15, a commitment or a
6court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the
7limitations regarding
selected participating providers, primary providers and
8referrals under ss. 609.01 (2) to (4) and 609.05 (3), the
health maintenance
9organization, limited service health organization
or
, preferred provider plan
or
10managed care plan shall do all of the following:
AB768-ASA1,439,1812
609.65
(1) (a) If the provider performing the examination, evaluation or
13treatment has a provider agreement with the
health maintenance organization,
14limited service health organization
or, preferred provider plan
or managed care plan 15which covers the provision of that service to the
enrolled participant enrollee, make
16the service available to the
enrolled participant
enrollee in accordance with the
17terms of the
health care limited service health organization, preferred provider plan
18or managed care plan and the provider agreement.
AB768-ASA1,440,220
609.65
(1) (b) (intro.) If the provider performing the examination, evaluation
21or treatment does not have a provider agreement with the
health maintenance
22organization, limited service health organization
or
, preferred provider plan
or
23managed care plan which covers the provision of that service to the
enrolled
24participant enrollee, reimburse the provider for the examination, evaluation or
25treatment of the
enrolled participant enrollee in an amount not to exceed the
1maximum reimbursement for the service under the medical assistance program
2under subch. IV of ch. 49, if any of the following applies:
AB768-ASA1,440,84
609.65
(1) (b) 1. The service is provided pursuant to a commitment or a court
5order, except that reimbursement is not required under this subdivision if the
health
6maintenance organization, limited service health organization
or, preferred provider
7plan
or managed care plan could have provided the service through a provider with
8whom it has a provider agreement.
AB768-ASA1,440,1410
609.65
(1) (b) 2. The service is provided pursuant to an emergency detention
11under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20
12and the provider notifies the
health maintenance organization, limited service
13health organization
or, preferred provider plan
or managed care plan within 72
14hours after the initial provision of the service.
AB768-ASA1,440,2216
609.65
(2) If after receiving notice under sub. (1) (b) 2. the
health maintenance
17organization, limited service health organization
or
, preferred provider plan
or
18managed care plan arranges for services to be provided by a provider with whom it
19has a provider agreement, the
health maintenance organization, limited service
20health organization
or, preferred provider plan
or managed care plan is not required
21to reimburse a provider under sub. (1) (b) 2. for any services provided after
22arrangements are made under this subsection.
AB768-ASA1,441,824
609.65
(3) A
health maintenance organization, limited service health
25organization
or, preferred provider plan
or managed care plan is only required to
1make available, or make reimbursement for, an examination, evaluation or
2treatment under sub. (1) to the extent that the
health maintenance organization, 3limited service health organization
or, preferred provider plan
or managed care plan 4would have made the medically necessary service available to the
enrolled
5participant enrollee or reimbursed the provider for the service if any referrals
6required under s. 609.05 (3) had been made and the service had been performed by
7a
participating provider
selected by the health maintenance organization, limited
8service health organization or preferred provider plan.
AB768-ASA1,441,1210
609.655
(1) (a) 1. Is covered as a dependent child under the terms of a policy
11or certificate issued by a
health maintenance organization managed care plan
12insurer.
AB768-ASA1,441,1614
609.655
(1) (a) 2. Is enrolled in a school located in this state but outside the
15geographical service area of the
health maintenance organization managed care
16plan.
AB768-ASA1,441,2018
609.655
(1) (c) "School" means a technical college;
a center or an institution
19within the university of Wisconsin system; and any institution of higher education
20that grants a bachelor's or higher degree.
AB768-ASA1,442,522
609.655
(2) If a policy or certificate issued by a
health maintenance
23organization managed care plan insurer provides coverage of outpatient services
24provided to a dependent student, the policy or certificate shall provide coverage of
25outpatient services, to the extent and in the manner required under sub. (3), that are
1provided to the dependent student while he or she is attending a school located in this
2state but outside the geographical service area of the
health maintenance
3organization managed care plan, notwithstanding the limitations regarding
selected 4participating providers, primary providers and referrals under ss. 609.01 (2) and
5609.05 (3).
AB768-ASA1,442,97
609.655
(3) (intro.) Except as provided in sub. (5), a
health maintenance
8organization managed care plan shall provide coverage for all of the following
9services:
AB768-ASA1,442,1611
609.655
(3) (a) A clinical assessment of the dependent student's nervous or
12mental disorders or alcoholism or other drug abuse problems, conducted by a
13provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in
14reasonably close proximity to the school in which the dependent student is enrolled
15and who may be designated by the
health maintenance organization managed care
16plan.
AB768-ASA1,442,2318
609.655
(3) (b) (intro.) If outpatient services are recommended in the clinical
19assessment conducted under par. (a), the recommended outpatient services
20consisting of not more than 5 visits to an outpatient treatment facility or other
21provider that is located in this state and in reasonably close proximity to the school
22in which the dependent student is enrolled and that may be designated by the
health
23maintenance organization managed care plan, except as follows:
AB768-ASA1,443,4
1609.655
(3) (b) 1. Coverage is not required under this paragraph if the medical
2director of the
health maintenance organization managed care plan determines that
3the nature of the treatment recommended in the clinical assessment will prohibit the
4dependent student from attending school on a regular basis.
AB768-ASA1,443,156
609.655
(4) (a) Upon completion of the 5 visits for outpatient services covered
7under sub. (3) (b), the medical director of the
health maintenance organization 8managed care plan and the clinician treating the dependent student shall review the
9dependent student's condition and determine whether it is appropriate to continue
10treatment of the dependent student's nervous or mental disorders or alcoholism or
11other drug abuse problems in reasonably close proximity to the school in which the
12student is enrolled. The review is not required if the dependent student is no longer
13enrolled in the school or if the coverage limits under the policy or certificate for
14treatment of nervous or mental disorders or alcoholism or other drug abuse problems
15have been exhausted.
AB768-ASA1,443,2517
609.655
(4) (b) Upon completion of the review under par. (a), the medical
18director of the
health maintenance organization managed care plan shall determine
19whether the policy or certificate will provide coverage of any further treatment for
20the dependent student's nervous or mental disorder or alcoholism or other drug
21abuse problems that is provided by a provider located in reasonably close proximity
22to the school in which the student is enrolled. If the dependent student disputes the
23medical director's determination, the dependent student may submit a written
24grievance under the
health maintenance organization's
managed care plan's 25internal grievance procedure established under s. 609.15.
AB768-ASA1,444,72
609.655
(5) (a) A policy or certificate issued by a
health maintenance
3organization managed care plan insurer is required to provide coverage for the
4services specified in sub. (3) only to the extent that the policy or certificate would
5have covered the service if it had been provided to the dependent student by a
6selected participating provider within the geographical service area of the
health
7maintenance organization managed care plan.
AB768-ASA1,444,149
609.655
(5) (b) Paragraph (a) does not permit a
health maintenance
10organization managed care plan to reimburse a provider for less than the full cost
11of the services provided or an amount negotiated with the provider, solely because
12the reimbursement rate for the service would have been less if provided by a
selected 13participating provider within the geographical service area of the
health
14maintenance organization managed care plan.
AB768-ASA1,444,18
16609.70 Chiropractic coverage. Health maintenance organizations, limited
17Limited service health organizations
and
, preferred provider plans
and managed
18care plans are subject to s. 632.87 (3).
AB768-ASA1,445,2
20609.75 Adopted children coverage.
Health maintenance organizations,
21limited Limited service health organizations
and, preferred provider plans
and
22managed care plans are subject to s. 632.896. Coverage of health care services
23obtained by adopted children and children placed for adoption may be subject to any
24requirements that the
health maintenance organization, limited service health
25organization
or, preferred provider plan
or managed care plan imposes under s.
1609.05 (2) and (3) on the coverage of health care services obtained by other
enrolled
2participants enrollees.
AB768-ASA1,445,7
5609.77 Coverage of breast reconstruction. Health maintenance
6organizations, limited Limited service health organizations
and, preferred provider
7plans
and managed care plans are subject to s. 632.895 (13).
AB768-ASA1,445,13
10609.78 Coverage of treatment for the correction of
11temporomandibular disorders. Health maintenance organizations, limited 12Limited service health organizations
and
, preferred provider plans
and managed
13care plans are subject to s. 632.895 (11).
AB768-ASA1,445,19
16609.79 Coverage of hospital and ambulatory surgery center charges
17and anesthetics for dental care. Health maintenance organizations, limited 18Limited service health organizations
and
, preferred provider plans
and managed
19care plans are subject to s. 632.895 (12).
AB768-ASA1,446,2
21609.80 Coverage of mammograms. Health maintenance organizations and
22preferred provider Managed care plans are subject to s. 632.895 (8). Coverage of
23mammograms under s. 632.895 (8) may be subject to any requirements that the
24health maintenance organization or preferred provider
managed care plan imposes
1under s. 609.05 (2) and (3) on the coverage of other health care services obtained by
2enrolled participants enrollees.
AB768-ASA1,446,8
4609.81 Coverage related to HIV infection. Health maintenance
5organizations, limited Limited service health organizations
and, preferred provider
6plans
and managed care plans are subject to s. 631.93.
Health maintenance
7organizations and preferred provider Managed care plans are subject to s. 632.895
8(9).
AB768-ASA1,446,12
10609.82 Coverage without prior authorization for emergency medical
11condition treatment. Health maintenance organizations, limited service health
12organizations and preferred provider plans are subject to s. 632.85.
AB768-ASA1, s. 566cjy
13Section 566cjy. 609.82 of the statutes, as created by 1997 Wisconsin Act ....
14(this act), is repealed and recreated to read:
AB768-ASA1,446,17
15609.82 Coverage without prior authorization for emergency medical
16condition treatment. Limited service health organizations, preferred provider
17plans and managed care plans are subject to s. 632.85.
AB768-ASA1,446,21
19609.83 Coverage of drugs and devices. Limited service health
20organizations, preferred provider plans and managed care plans are subject to s.
21632.853.
AB768-ASA1,446,24
23609.84 Experimental treatment. Limited service health organizations,
24preferred provider plans and managed care plans are subject to s. 632.855.
AB768-ASA1,447,6
1609.91
(1) (title)
Immunity of enrolled participants enrollees and
2policyholders. (intro.) Except as provided in sub. (1m), an
enrolled participant 3enrollee or policyholder of a health maintenance organization insurer is not liable for
4health care costs that are incurred on or after January 1, 1990, and that are covered
5under a policy or certificate issued by the health maintenance organization insurer,
6if any of the following applies:
AB768-ASA1,447,108
609.91
(1) (b) 2. Is physician services provided under a contract with the health
9maintenance organization insurer or by a
selected
participating provider of the
10health maintenance organization insurer.
AB768-ASA1,447,1412
609.91
(1) (b) 3. Is services, equipment, supplies or drugs that are ancillary or
13incidental to services described in subd. 2. and are provided by the contracting
14provider or
selected participating provider.
AB768-ASA1,447,2016
609.91
(1m) Immunity of medical assistance recipients. An
enrolled
17participant enrollee, policyholder or insured under a policy issued by an insurer to
18the department of health and family services under s. 49.45 (2) (b) 2. to provide
19prepaid health care to medical assistance recipients is not liable for health care costs
20that are covered under the policy.
AB768-ASA1,448,222
609.91
(2) Prohibited recovery attempts. No person may bill, charge, collect
23a deposit from, seek remuneration or compensation from, file or threaten to file with
24a credit reporting agency or have any recourse against an
enrolled participant 25enrollee, policyholder or insured, or any person acting on their behalf, for health care
1costs for which the
enrolled participant
enrollee, policyholder or insured, or person
2acting on their behalf, is not liable under sub. (1) or (1m).
AB768-ASA1,448,84
609.91
(3) Deductibles, copayments and premiums. Subsections (1) to (2) do not
5affect the liability of an
enrolled participant enrollee, policyholder or insured for any
6deductibles, copayments or premiums owed under the policy or certificate issued by
7the health maintenance organization insurer or by the insurer described in sub.
8(1m).
AB768-ASA1,448,1310
609.91
(4) (intro.)
Conditions not affecting the immunity. The immunity of
11an
enrolled participant enrollee, policyholder or insured for health care costs, to the
12extent of the immunity provided under this section and ss. 609.92 to 609.935, is not
13affected by any of the following:
AB768-ASA1,448,2015
609.91
(4) (a) An agreement, other than a notice of election or termination of
16election in accordance with s. 609.92 or 609.925, entered into by the provider, the
17health maintenance organization insurer, the insurer described in sub. (1m) or any
18other person, at any time, whether oral or written and whether implied or explicit,
19including an agreement that purports to hold the
enrolled participant enrollee,
20policyholder or insured liable for health care costs.
AB768-ASA1,449,222
609.91
(4) (b) A breach of or default on an agreement by the health
23maintenance organization insurer, the insurer described in sub. (1m) or any other
24person to compensate the provider, directly or indirectly, for health care costs,
1including health care costs for which the
enrolled participant enrollee, policyholder
2or insured is not liable under sub. (1) or (1m).