SB55-SSA1-CA1,914,2318
562.065
(4) Unclaimed prizes. Any A licensee under s. 562.05 (1) (b) shall pay
19to the department 50% of any winnings on a race
which that are not claimed within
2090 days after the end of the period authorized for racing in that year under s. 562.05
21(9)
shall be paid to the department. The department shall credit moneys received
22under this subsection to the appropriation accounts under ss. 20.455 (2) (g) and
2320.505 (8) (g).
The licensee may retain the remaining 50% of the winnings.".
SB55-SSA1-CA1,915,82
601.73
(2) (c)
Default judgment. No plaintiff or complainant is entitled to a
3judgment by default in any proceeding in which process is served under this section
4and s. 601.72 until the expiration of 45 days after the date of mailing of the process
5under par. (b)
. If the proceeding is to foreclose or otherwise enforce a lien or security
6interest, the plaintiff or complainant is not entitled to a judgment by default under
7this paragraph until the expiration of 20 days after the date of mailing of the process
8under par. (b).".
SB55-SSA1-CA1,915,12
12MANAGED CARE Defined network PLANS
SB55-SSA1-CA1,915,1614
609.01
(1d) "Enrollee" means, with respect to a
managed care defined network 15plan, preferred provider plan
, or limited service health organization, a person who
16is entitled to receive health care services under the plan.
SB55-SSA1-CA1,915,2319
609.01
(1b) "
Managed care Defined network plan" means a health benefit plan
20that requires an enrollee of the health benefit plan, or creates incentives, including
21financial incentives, for an enrollee of the health benefit plan, to use providers that
22are managed, owned, under contract with
, or employed by the insurer offering the
23health benefit plan.
SB55-SSA1-CA1,916,5
1609.01
(3m) "Participating" means, with respect to a physician or other
2provider, under contract with a
managed care defined network plan, preferred
3provider plan
, or limited service health organization to provide health care services,
4items or supplies to enrollees of the
managed care
defined network plan, preferred
5provider plan
, or limited service health organization.
SB55-SSA1-CA1,916,137
609.01
(4) "Preferred provider plan" means a health care plan offered by an
8organization established under ch. 185, 611, 613
, or 614 or issued a certificate of
9authority under ch. 618 that makes available to its enrollees,
without referral and 10for consideration other than predetermined periodic fixed payments,
coverage of 11either comprehensive health care services or a limited range of health care services
,
12regardless of whether the health care services are performed by
participating or
13nonparticipating providers
participating in the plan.
SB55-SSA1-CA1,916,1815
609.01
(5) "Primary provider" means a participating primary care physician,
16or other participating provider authorized by the
managed care defined network 17plan, preferred provider plan
, or limited service health organization to serve as a
18primary provider, who coordinates and may provide ongoing care to an enrollee.
SB55-SSA1-CA1,916,2220
609.05
(1) Except as provided in subs. (2) and (3), a limited service health
21organization, preferred provider plan
, or
managed care defined network plan shall
22permit its enrollees to choose freely among participating providers.
SB55-SSA1-CA1,917,224
609.05
(2) Subject to s. 609.22 (4) and (4m), a limited service health
25organization, preferred provider plan
, or
managed care defined network plan may
1require an enrollee to designate a primary provider and to obtain health care services
2from the primary provider when reasonably possible.
SB55-SSA1-CA1,917,84
609.05
(3) Except as provided in ss. 609.22 (4m), 609.65
, and 609.655, a limited
5service health organization, preferred provider plan
, or
managed care defined
6network plan may require an enrollee to obtain a referral from the primary provider
7designated under sub. (2) to another participating provider prior to obtaining health
8care services from that participating provider.
SB55-SSA1-CA1,917,1210
609.10
(5) The commissioner may establish by rule standards in addition to
11those any established under s. 609.20 for what constitutes adequate notice and
12complete and understandable information under sub. (1) (c).
SB55-SSA1-CA1,917,19
14609.17 Reports of disciplinary action. Every limited service health
15organization, preferred provider plan
, and
managed care defined network plan shall
16notify the medical examining board or appropriate affiliated credentialing board
17attached to the medical examining board of any disciplinary action taken against a
18participating provider who holds a license or certificate granted by the board or
19affiliated credentialing board.
SB55-SSA1-CA1,917,22
21609.20 (title)
Rules for preferred provider and managed care defined
22network plans.
SB55-SSA1-CA1, s. 3741dmp
23Section 3741dmp. 609.20 (intro.) of the statutes is renumbered 609.20 (1m)
24(intro.) and amended to read:
SB55-SSA1-CA1,918,3
1609.20
(1m) (intro.) The commissioner
shall may promulgate rules relating to
2preferred provider plans and
managed care defined network plans for
all any of the
3following purposes
, as appropriate:
SB55-SSA1-CA1,918,117
609.20
(2m) Any rule promulgated under this chapter shall recognize the
8differences between preferred provider plans and other types of defined network
9plans, take into account the fact that preferred provider plans provide coverage for
10the services of nonparticipating providers, and be appropriate to the type of plan to
11which the rule applies.
SB55-SSA1-CA1,918,2017
609.22
(1) Providers. A
managed care defined network plan shall include a
18sufficient number, and sufficient types, of
qualified providers to meet the anticipated
19needs of its enrollees, with respect to covered benefits
, as appropriate to the type of
20plan and consistent with normal practices and standards in the geographic area.
SB55-SSA1-CA1,918,2522
609.22
(2) Adequate choice. A
managed care defined network plan
that is not
23a preferred provider plan shall ensure that, with respect to covered benefits, each
24enrollee has adequate choice among participating providers and that the providers
25are accessible and qualified.
SB55-SSA1-CA1,919,92
609.22
(3) Primary provider selection. A
managed care defined network plan
3that is not a preferred provider plan shall permit each enrollee to select his or her
4own primary provider from a list of participating primary care physicians and any
5other participating providers that are authorized by the
managed care defined
6network plan to serve as primary providers. The list shall be updated on an ongoing
7basis and shall include a sufficient number of primary care physicians and any other
8participating providers authorized by the plan to serve as primary providers who are
9accepting new enrollees.
SB55-SSA1-CA1,919,1611
609.22
(4) (a) 1. If a
managed care
defined network plan
that is not a preferred
12provider plan requires a referral to a specialist for coverage of specialist services, the
13managed care defined network plan
that is not a preferred provider plan shall
14establish a procedure by which an enrollee may apply for a standing referral to a
15specialist. The procedure must specify the criteria and conditions that must be met
16in order for an enrollee to obtain a standing referral.
SB55-SSA1-CA1,920,218
609.22
(4) (a) 2. A
managed care
defined network plan
that is not a preferred
19provider plan may require the enrollee's primary provider to remain responsible for
20coordinating the care of an enrollee who receives a standing referral to a specialist.
21A
managed care defined network plan
that is not a preferred provider plan may
22restrict the specialist from making any secondary referrals without prior approval
23by the enrollee's primary provider. If an enrollee requests primary care services from
24a specialist to whom the enrollee has a standing referral, the specialist, in agreement
25with the enrollee and the enrollee's primary provider, may provide primary care
1services to the enrollee in accordance with procedures established by the
managed
2care defined network plan
that is not a preferred provider plan.
SB55-SSA1-CA1,920,74
609.22
(4) (a) 3. A
managed care
defined network plan
that is not a preferred
5provider plan must include information regarding referral procedures in policies or
6certificates provided to enrollees and must provide such information to an enrollee
7or prospective enrollee upon request.
SB55-SSA1-CA1,920,179
609.22
(4m) (a) A
managed care defined network plan that provides coverage
10of obstetric or gynecologic services may not require a female enrollee of the
managed
11care defined network plan to obtain a referral for covered obstetric or gynecologic
12benefits provided by a participating provider who is a physician licensed under ch.
13448 and who specializes in obstetrics and gynecology, regardless of whether the
14participating provider is the enrollee's primary provider. Notwithstanding sub. (4),
15the
managed care defined network plan may not require the enrollee to obtain a
16standing referral under the procedure established under sub. (4) (a) for covered
17obstetric or gynecologic benefits.
SB55-SSA1-CA1,920,2019
609.22
(4m) (b) (intro.) A
managed care defined network plan under par. (a)
20may not do any of the following:
SB55-SSA1-CA1,920,2422
609.22
(4m) (c) A
managed care defined network plan under par. (a) shall
23provide written notice of the requirement under par. (a) in every policy or group
24certificate issued by the
managed care defined network plan.
SB55-SSA1-CA1,921,3
1609.22
(5) Second opinions. A
managed care defined network plan shall
2provide an enrollee with coverage for a 2nd opinion from another participating
3provider.
SB55-SSA1-CA1,921,75
609.22
(6) Emergency care. (intro.) Notwithstanding s. 632.85, if a
managed
6care defined network plan provides coverage of emergency services, with respect to
7covered benefits, the
managed care defined network plan shall do all of the following:
SB55-SSA1-CA1,921,159
609.22
(7) Telephone access. A
managed care defined network plan
that is not
10a preferred provider plan shall provide telephone access for sufficient time during
11business and evening hours to ensure that enrollees have adequate access to routine
12health care services for which coverage is provided under the plan. A
managed care 13defined network plan
that is not a preferred provider plan shall provide 24-hour
14telephone access to the plan or to a participating provider for emergency care, or
15authorization for care, for which coverage is provided under the plan.
SB55-SSA1-CA1,921,2217
609.22
(8) Access plan for certain enrollees. A
managed care defined
18network plan shall develop an access plan to meet the needs, with respect to covered
19benefits, of its enrollees who are members of underserved populations. If a
20significant number of enrollees of the plan customarily use languages other than
21English, the
managed care defined network plan shall provide access to translation
22services fluent in those languages to the greatest extent possible.
SB55-SSA1-CA1,922,524
609.24
(1) (a) (intro.) Subject to pars. (b) and (c) and except as provided in par.
25(d), a
managed care defined network plan shall, with respect to covered benefits,
1provide coverage to an enrollee for the services of a provider, regardless of whether
2the provider is a participating provider at the time the services are provided, if the
3managed care defined network plan represented that the provider was, or would be,
4a participating provider in marketing materials that were provided or available to
5the enrollee at any of the following times:
SB55-SSA1-CA1,922,97
609.24
(1) (b) (intro.) Except as provided in par. (d), a
managed care defined
8network plan shall provide the coverage required under par. (a) with respect to the
9services of a provider who is a primary care physician for the following period of time:
SB55-SSA1-CA1,922,1511
609.24
(1) (c) (intro.) Except as provided in par. (d), if an enrollee is undergoing
12a course of treatment with a participating provider who is not a primary care
13physician and whose participation with the plan terminates, the
managed care 14defined network plan shall provide the coverage under par. (a) with respect to the
15services of the provider for the following period of time:
SB55-SSA1-CA1,922,1817
609.24
(1) (d) 1. The provider no longer practices in the
managed care defined
18network plan's geographic service area.
SB55-SSA1-CA1,922,2220
609.24
(1) (d) 2. The insurer issuing the
managed care defined network plan
21terminates or terminated the provider's contract for misconduct on the part of the
22provider.
SB55-SSA1-CA1,923,3
1609.24
(1) (e) 1. An insurer issuing a
managed care defined network plan shall
2include in its provider contracts provisions addressing reimbursement to providers
3for services rendered under this section.
SB55-SSA1-CA1,923,85
609.24
(1) (e) 2. If a contract between a
managed care defined network plan and
6a provider does not address reimbursement for services rendered under this section,
7the insurer shall reimburse the provider according to the most recent contracted
8rate.
SB55-SSA1-CA1,923,1410
609.24
(4) Notice of provisions. A defined network plan shall notify all plan
11enrollees of the provisions under this section whenever a participating provider's
12participation with the plan terminates, or shall, by contract, require a participating
13provider to notify all plan enrollees of the provisions under this section if the
14participating provider's participation with the plan terminates.
SB55-SSA1-CA1,923,1916
609.30
(1) Plan may not contract. A
managed care defined network plan may
17not contract with a participating provider to limit the provider's disclosure of
18information, to or on behalf of an enrollee, about the enrollee's medical condition or
19treatment options.
SB55-SSA1-CA1,924,221
609.30
(2) Plan may not penalize or terminate. A participating provider may
22discuss, with or on behalf of an enrollee, all treatment options and any other
23information that the provider determines to be in the best interest of the enrollee.
24A
managed care defined network plan may not penalize or terminate the contract of
25a participating provider because the provider makes referrals to other participating
1providers or discusses medically necessary or appropriate care with or on behalf of
2an enrollee.
SB55-SSA1-CA1,924,84
609.32
(1) Standards; other than preferred provider plans. (intro.) A
5managed care defined network plan
that is not a preferred provider plan shall
6develop comprehensive quality assurance standards that are adequate to identify,
7evaluate
, and remedy problems related to access to, and continuity and quality of,
8care. The standards shall include at least all of the following:
SB55-SSA1-CA1,924,1310
609.32
(1m) Procedure for remedial action; preferred provider plans. A
11preferred provider plan shall develop a procedure for remedial action to address
12quality problems, including written procedures for taking appropriate corrective
13action.
