Amendment AA1-ASA1-SB55

SB55-ASA1-AA1, s. 3741nmg Section 3741nmg. 609.36 (2) of the statutes is amended to read:

SB55-ASA1-AA1,1305,14 609.36 (2) Confidentiality. A managed care defined network plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82, and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.

SB55-ASA1-AA1, s. 3741nmp Section 3741nmp. 609.38 of the statutes is amended to read:

SB55-ASA1-AA1,1305,19 609.38 Oversight. The office shall perform examinations of insurers that issue managed care defined network plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for managed care defined network plans for compliance with the requirements under this chapter.

SB55-ASA1-AA1, s. 3741nmt Section 3741nmt. 609.65 (1) (intro.) of the statutes is amended to read:

SB55-ASA1-AA1,1306,3 609.65 (1) (intro.) If an enrollee of a limited service health organization, preferred provider plan, or managed care defined network plan is examined, evaluated, or treated for a nervous or mental disorder pursuant to an emergency detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the limited service health organization, preferred provider plan, or managed care defined network plan shall do all of the following:

SB55-ASA1-AA1, s. 3741omg Section 3741omg. 609.65 (1) (a) of the statutes is amended to read:

SB55-ASA1-AA1,1306,10 609.65 (1) (a) If the provider performing the examination, evaluation, or treatment has a provider agreement with the limited service health organization, preferred provider plan, or managed care defined network plan which covers the provision of that service to the enrollee, make the service available to the enrollee in accordance with the terms of the limited service health organization, preferred provider plan, or managed care defined network plan and the provider agreement.

SB55-ASA1-AA1, s. 3741omp Section 3741omp. 609.65 (1) (b) (intro.) of the statutes is amended to read:

SB55-ASA1-AA1,1306,18 609.65 (1) (b) (intro.) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the limited service health organization, preferred provider plan, or managed care defined network plan which covers the provision of that service to the enrollee, reimburse the provider for the examination, evaluation, or treatment of the enrollee in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:

SB55-ASA1-AA1, s. 3741omt Section 3741omt. 609.65 (1) (b) 1. of the statutes is amended to read:

SB55-ASA1-AA1,1306,24 609.65 (1) (b) 1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the limited service health organization, preferred provider plan, or managed care defined network plan could have provided the service through a provider with whom it has a provider agreement.

SB55-ASA1-AA1, s. 3741pmg Section 3741pmg. 609.65 (1) (b) 2. of the statutes is amended to read:

SB55-ASA1-AA1,1307,5 609.65 (1) (b) 2. The service is provided pursuant to an emergency detention under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20 and the provider notifies the limited service health organization, preferred provider plan, or managed care defined network plan within 72 hours after the initial provision of the service.

SB55-ASA1-AA1, s. 3741pmp Section 3741pmp. 609.65 (2) of the statutes is amended to read:

SB55-ASA1-AA1,1307,12 609.65 (2) If after receiving notice under sub. (1) (b) 2. the limited service health organization, preferred provider plan, or managed care defined network plan arranges for services to be provided by a provider with whom it has a provider agreement, the limited service health organization, preferred provider plan, or managed care plan is not required to reimburse a provider under sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.

SB55-ASA1-AA1, s. 3741pmt Section 3741pmt. 609.65 (3) of the statutes is amended to read:

SB55-ASA1-AA1,1307,21 609.65 (3) A limited service health organization, preferred provider plan, or managed care defined network plan is only required to make available, or make reimbursement for, an examination, evaluation, or treatment under sub. (1) to the extent that the limited service health organization, preferred provider plan, or managed care defined network plan would have made the medically necessary service available to the enrollee or reimbursed the provider for the service if any referrals required under s. 609.05 (3) had been made and the service had been performed by a participating provider.

SB55-ASA1-AA1, s. 3741qmg Section 3741qmg. 609.655 (1) (a) 1. of the statutes is amended to read:

SB55-ASA1-AA1,1307,24 609.655 (1) (a) 1. Is covered as a dependent child under the terms of a policy or certificate issued by a managed care defined network plan insurer.

SB55-ASA1-AA1, s. 3741qmp Section 3741qmp. 609.655 (1) (a) 2. of the statutes is amended to read:

SB55-ASA1-AA1,1308,2 609.655 (1) (a) 2. Is enrolled in a school located in this state but outside the geographical service area of the managed care defined network plan.

SB55-ASA1-AA1, s. 3741qmt Section 3741qmt. 609.655 (2) of the statutes is amended to read:

SB55-ASA1-AA1,1308,11 609.655 (2) If a policy or certificate issued by a managed care defined network plan insurer provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the managed care defined network plan, notwithstanding the limitations regarding participating providers, primary providers, and referrals under ss. 609.01 (2) and 609.05 (3).

SB55-ASA1-AA1, s. 3741rmg Section 3741rmg. 609.655 (3) (intro.) of the statutes is amended to read:

SB55-ASA1-AA1,1308,14 609.655 (3) (intro.) Except as provided in sub. (5), a managed care defined network plan shall provide coverage for all of the following services:

SB55-ASA1-AA1, s. 3741rmp Section 3741rmp. 609.655 (3) (a) of the statutes is amended to read:

SB55-ASA1-AA1,1308,20 609.655 (3) (a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the managed care defined network plan.

SB55-ASA1-AA1, s. 3741smg Section 3741smg. 609.655 (3) (b) (intro.) of the statutes is amended to read:

SB55-ASA1-AA1,1309,2 609.655 (3) (b) (intro.) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the managed care defined network plan, except as follows:

SB55-ASA1-AA1, s. 3741smp Section 3741smp. 609.655 (3) (b) 1. of the statutes is amended to read:

SB55-ASA1-AA1,1309,7 609.655 (3) (b) 1. Coverage is not required under this paragraph if the medical director of the managed care defined network plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.

SB55-ASA1-AA1, s. 3741smt Section 3741smt. 609.655 (4) (a) of the statutes is amended to read:

SB55-ASA1-AA1,1309,17 609.655 (4) (a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the managed care defined network plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.

SB55-ASA1-AA1, s. 3741tmg Section 3741tmg. 609.655 (4) (b) of the statutes is amended to read:

SB55-ASA1-AA1,1310,2 609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the managed care defined network plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the managed care defined network plan's internal grievance procedure established under s. 632.83.

SB55-ASA1-AA1, s. 3741tmp Section 3741tmp. 609.655 (5) (a) of the statutes is amended to read:

SB55-ASA1-AA1,1310,8 609.655 (5) (a) A policy or certificate issued by a managed care defined network plan insurer is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a participating provider within the geographical service area of the managed care defined network plan.

SB55-ASA1-AA1, s. 3741tmt Section 3741tmt. 609.655 (5) (b) of the statutes is amended to read:

SB55-ASA1-AA1,1310,14 609.655 (5) (b) Paragraph (a) does not permit a managed care defined network plan to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a participating provider within the geographical service area of the managed care defined network plan.

SB55-ASA1-AA1, s. 3741umg Section 3741umg. 609.70 of the statutes is amended to read:

SB55-ASA1-AA1,1310,18 609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.87 (3).

SB55-ASA1-AA1, s. 3741ump Section 3741ump. 609.75 of the statutes is amended to read:

SB55-ASA1-AA1,1311,2 609.75 Adopted children coverage. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the limited service health organization, preferred provider plan, or managed care defined network plan imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained by other enrollees.

SB55-ASA1-AA1, s. 3741umt Section 3741umt. 609.77 of the statutes is amended to read:

SB55-ASA1-AA1,1311,6 609.77 Coverage of breast reconstruction. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.895 (13).

SB55-ASA1-AA1, s. 3741vmg Section 3741vmg. 609.78 of the statutes is amended to read:

SB55-ASA1-AA1,1311,11 609.78 Coverage of treatment for the correction of temporomandibular disorders. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.895 (11).

SB55-ASA1-AA1, s. 3741vmp Section 3741vmp. 609.79 of the statutes is amended to read:

SB55-ASA1-AA1,1311,16 609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.895 (12).

SB55-ASA1-AA1, s. 3741vmt Section 3741vmt. 609.80 of the statutes is amended to read:

SB55-ASA1-AA1,1311,22 609.80 Coverage of mammograms. Managed care Defined network plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the managed care defined network plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrollees.

SB55-ASA1-AA1, s. 3741wmg Section 3741wmg. 609.81 of the statutes is amended to read:

SB55-ASA1-AA1,1312,2 609.81 Coverage related to HIV infection. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 631.93. Managed care Defined network plans are subject to s. 632.895 (9).

SB55-ASA1-AA1, s. 3741wmp Section 3741wmp. 609.82 of the statutes is amended to read:

SB55-ASA1-AA1,1312,6 609.82 Coverage without prior authorization for emergency medical condition treatment. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.85.

SB55-ASA1-AA1, s. 3741wmt Section 3741wmt. 609.83 of the statutes is amended to read:

SB55-ASA1-AA1,1312,10 609.83 Coverage of drugs and devices. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.853.

SB55-ASA1-AA1, s. 3741xmg Section 3741xmg. 609.84 of the statutes is amended to read:

SB55-ASA1-AA1,1312,14 609.84 Experimental treatment. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.855.

SB55-ASA1-AA1, s. 3741xmp Section 3741xmp. 609.88 of the statutes is amended to read:

SB55-ASA1-AA1,1312,17 609.88 Coverage of immunizations. Managed care Defined network plans are subject to s. 632.895 (14).

SB55-ASA1-AA1, s. 3741xmr Section 3741xmr. 609.89 of the statutes is amended to read:

SB55-ASA1-AA1,1312,21 609.89 Written reason for coverage denial. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 631.17.

SB55-ASA1-AA1, s. 3741xmt Section 3741xmt. 609.90 of the statutes is amended to read:

SB55-ASA1-AA1,1312,25 609.90 Restrictions related to domestic abuse. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 631.95.".

SB55-ASA1-AA1,1313,1 1737. Page 1181, line 3: after that line insert:

SB55-ASA1-AA1,1313,2 " Section 3760rm. 632.872 of the statutes is created to read:

SB55-ASA1-AA1,1313,4 632.872 Prohibiting denial of payment for certain procedures. (1) In this section:

SB55-ASA1-AA1,1313,5 (a) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).

SB55-ASA1-AA1,1313,7 (b) "Medicare Part B" means the federal supplementary medical insurance program under 42 USC 1395j to 1395w-2.

SB55-ASA1-AA1,1313,13 (2) An insurer may not deny payment under an individual or group disability insurance policy or a certificate of group disability insurance for a medical or surgical service or procedure on the basis that the service or procedure is an integral component of a 2nd medical or surgical service or procedure unless, under medicare Part B, payment for the first service or procedure is included in the payment for the 2nd service or procedure.".

SB55-ASA1-AA1,1313,14 1738. Page 1181, line 12: after that line insert:

SB55-ASA1-AA1,1313,15 " Section 3766e. 635.02 (2) of the statutes is amended to read:

SB55-ASA1-AA1,1313,21 635.02 (2) "Case characteristics" means the demographic, actuarially based characteristics of the employees of a small employer, and the employer, if covered, such as age, sex, and geographic location and occupation, used by a small employer insurer to determine premium rates for a small employer. "Case characteristics" does not include loss or claim history, health status, occupation, duration of coverage, or other factors related to claim experience.

SB55-ASA1-AA1, s. 3766ec Section 3766ec. 635.02 (3e) of the statutes is created to read:

SB55-ASA1-AA1,1313,23 635.02 (3e) "Eligible employee" has the meaning given in s. 632.745 (5) (a).

SB55-ASA1-AA1, s. 3766ef Section 3766ef. 635.02 (7) of the statutes is amended to read:

SB55-ASA1-AA1,1314,7 635.02 (7) "Small employer" means, with respect to a calendar year and a plan year, an employer that employed an average of at least 2 but not more than 50 eligible employees on business days during the preceding calendar year, or that is reasonably expected to employ an average of at least 2 but not more than 50 eligible employees on business days during the current calendar year if the employer was not in existence during the preceding calendar year, and that employs at least 2 eligible employees on the first day of the plan year.

SB55-ASA1-AA1, s. 3766f Section 3766f. 635.05 (2) (a) 2. of the statutes is amended to read:

SB55-ASA1-AA1,1314,12 635.05 (2) (a) 2. An adjustment, not to exceed 15% per year, adjusted proportionally for rating periods of less than one year, for such rating factors as claim experience, health status, occupation, and duration of coverage, determined in accordance with the small employer insurer's rate manual or rating procedures.

SB55-ASA1-AA1, s. 3766g Section 3766g. 635.05 (7) of the statutes is created to read:

SB55-ASA1-AA1,1314,15 635.05 (7) Specifying the manner in which rates must be published under s. 635.12.

SB55-ASA1-AA1, s. 3766j Section 3766j. 635.12 of the statutes is created to read:

SB55-ASA1-AA1,1314,22 635.12 Annual publication of rates. Every small employer insurer shall annually publish the small employer insurer's current new business premium rates. The rates shall be published in the manner and according to categories required by rule under s. 635.05 (7). New business premium rates for coverage under the health care coverage program under subch. X of ch. 40 shall be published as required under s. 40.98 (2) (d).".

SB55-ASA1-AA1,1314,23 1739. Page 1181, line 12: after that line insert:

SB55-ASA1-AA1,1314,24 " Section 3763f. 632.895 (14) (c) of the statutes is amended to read:

SB55-ASA1-AA1,1315,5 632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a managed care defined network plan, as defined in s. 609.01 (3c) (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

SB55-ASA1-AA1, s. 3763g Section 3763g. 632.895 (14) (d) 3. of the statutes is amended to read: