Amendment CA1-SSA1-SB55

SB55-SSA1-CA1, s. 3741mmy Section 3741mmy. 609.35 of the statutes is created to read:

SB55-SSA1-CA1,926,2 609.35 Applicability of requirements to preferred provider plans. Notwithstanding ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1), a preferred provider plan that does not cover the same services when performed by a nonparticipating provider that it covers when those services are performed by a participating provider is subject to the requirements under ss. 609.22 (2), (3), (4), and (7), 609.32 (1), and 609.34 (1).

SB55-SSA1-CA1, s. 3741mmz Section 3741mmz. 609.36 (1) (a) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,926,5 609.36 (1) (a) (intro.) A managed care defined network plan shall provide to the commissioner information related to all of the following:

SB55-SSA1-CA1, s. 3741nmg Section 3741nmg. 609.36 (2) of the statutes is amended to read:

SB55-SSA1-CA1,926,10 609.36 (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-SSA1-CA1, s. 3741nmp Section 3741nmp. 609.38 of the statutes is amended to read:

SB55-SSA1-CA1,926,15 609.38 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-SSA1-CA1, s. 3741nmt Section 3741nmt. 609.65 (1) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,926,24 609.65 (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-SSA1-CA1, s. 3741omg Section 3741omg. 609.65 (1) (a) of the statutes is amended to read:

SB55-SSA1-CA1,927,6 609.65 (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-SSA1-CA1, s. 3741omp Section 3741omp. 609.65 (1) (b) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,927,14 609.65 (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-SSA1-CA1, s. 3741omt Section 3741omt. 609.65 (1) (b) 1. of the statutes is amended to read:

SB55-SSA1-CA1,927,20 609.65 (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-SSA1-CA1, s. 3741pmg Section 3741pmg. 609.65 (1) (b) 2. of the statutes is amended to read:

SB55-SSA1-CA1,928,2 609.65 (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-SSA1-CA1, s. 3741pmp Section 3741pmp. 609.65 (2) of the statutes is amended to read:

SB55-SSA1-CA1,928,9 609.65 (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-SSA1-CA1, s. 3741pmt Section 3741pmt. 609.65 (3) of the statutes is amended to read:

SB55-SSA1-CA1,928,18 609.65 (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-SSA1-CA1, s. 3741qmg Section 3741qmg. 609.655 (1) (a) 1. of the statutes is amended to read:

SB55-SSA1-CA1,928,21 609.655 (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-SSA1-CA1, s. 3741qmp Section 3741qmp. 609.655 (1) (a) 2. of the statutes is amended to read:

SB55-SSA1-CA1,928,24 609.655 (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-SSA1-CA1, s. 3741qmt Section 3741qmt. 609.655 (2) of the statutes is amended to read:

SB55-SSA1-CA1,929,8 609.655 (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-SSA1-CA1, s. 3741rmg Section 3741rmg. 609.655 (3) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,929,11 609.655 (3) (intro.) Except as provided in sub. (5), a managed care defined network plan shall provide coverage for all of the following services:

SB55-SSA1-CA1, s. 3741rmp Section 3741rmp. 609.655 (3) (a) of the statutes is amended to read:

SB55-SSA1-CA1,929,17 609.655 (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-SSA1-CA1, s. 3741smg Section 3741smg. 609.655 (3) (b) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,929,24 609.655 (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-SSA1-CA1, s. 3741smp Section 3741smp. 609.655 (3) (b) 1. of the statutes is amended to read:

SB55-SSA1-CA1,930,4 609.655 (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-SSA1-CA1, s. 3741smt Section 3741smt. 609.655 (4) (a) of the statutes is amended to read:

SB55-SSA1-CA1,930,14 609.655 (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-SSA1-CA1, s. 3741tmg Section 3741tmg. 609.655 (4) (b) of the statutes is amended to read:

SB55-SSA1-CA1,930,24 609.655 (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-SSA1-CA1, s. 3741tmp Section 3741tmp. 609.655 (5) (a) of the statutes is amended to read:

SB55-SSA1-CA1,931,5 609.655 (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-SSA1-CA1, s. 3741tmt Section 3741tmt. 609.655 (5) (b) of the statutes is amended to read:

SB55-SSA1-CA1,931,11 609.655 (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-SSA1-CA1, s. 3741umg Section 3741umg. 609.70 of the statutes is amended to read:

SB55-SSA1-CA1,931,15 609.70 Chiropractic coverage. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.87 (3).

SB55-SSA1-CA1, s. 3741ump Section 3741ump. 609.75 of the statutes is amended to read:

SB55-SSA1-CA1,931,23 609.75 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-SSA1-CA1, s. 3741umt Section 3741umt. 609.77 of the statutes is amended to read:

SB55-SSA1-CA1,932,3 609.77 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-SSA1-CA1, s. 3741vmg Section 3741vmg. 609.78 of the statutes is amended to read:

SB55-SSA1-CA1,932,8 609.78 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-SSA1-CA1, s. 3741vmp Section 3741vmp. 609.79 of the statutes is amended to read:

SB55-SSA1-CA1,932,13 609.79 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-SSA1-CA1, s. 3741vmt Section 3741vmt. 609.80 of the statutes is amended to read:

SB55-SSA1-CA1,932,19 609.80 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-SSA1-CA1, s. 3741wmg Section 3741wmg. 609.81 of the statutes is amended to read:

SB55-SSA1-CA1,932,24 609.81 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-SSA1-CA1, s. 3741wmp Section 3741wmp. 609.82 of the statutes is amended to read:

SB55-SSA1-CA1,933,3 609.82 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-SSA1-CA1, s. 3741wmt Section 3741wmt. 609.83 of the statutes is amended to read:

SB55-SSA1-CA1,933,7 609.83 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-SSA1-CA1, s. 3741xmg Section 3741xmg. 609.84 of the statutes is amended to read:

SB55-SSA1-CA1,933,11 609.84 Experimental treatment. Limited service health organizations, preferred provider plans, and managed care defined network plans are subject to s. 632.855.

SB55-SSA1-CA1, s. 3741xmp Section 3741xmp. 609.88 of the statutes is amended to read:

SB55-SSA1-CA1,933,14 609.88 Coverage of immunizations. Managed care Defined network plans are subject to s. 632.895 (14).

SB55-SSA1-CA1, s. 3741xmr Section 3741xmr. 609.89 of the statutes is amended to read:

SB55-SSA1-CA1,933,18 609.89 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-SSA1-CA1, s. 3741xmt Section 3741xmt. 609.90 of the statutes is amended to read:

SB55-SSA1-CA1,933,22 609.90 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-SSA1-CA1,933,23 1473. Page 1180, line 21: after that line insert:

SB55-SSA1-CA1,933,24 " Section 3741d. 607.25 of the statutes is created to read:

SB55-SSA1-CA1,934,12 607.25 Loan to general fund. No later than the first day of the 2nd month after the effective date of this section .... [revisor inserts date], the life fund shall make a loan of $850,000 to the general fund. Notwithstanding s. 604.03 (2), no interest shall be charged on the loan during the period of the loan. The general fund shall repay the loan from moneys lapsed to the general fund from the appropriation under s. 20.515 (2) (a) at the end of the 2001-03 fiscal biennium, if any, and from moneys lapsed to the general fund from the appropriation under s. 20.515 (2) (g) in the amounts specified in s. 40.98 (6m). If the secretary of administration determines that the moneys lapsed from these appropriations will not be sufficient to repay the loan within a reasonable period of time, as determined by the secretary and the commissioner, the secretary shall transfer from the general fund to the life fund an amount sufficient to repay the loan.".

SB55-SSA1-CA1,934,13 1474. Page 1181, line 3: after that line insert:

SB55-SSA1-CA1,934,14 " Section 3755g. 628.46 (2m) of the statutes is created to read:

SB55-SSA1-CA1,934,19 628.46 (2m) Notwithstanding subs. (1) and (2), a claim for payment for chiropractic services is overdue if not paid within 30 days after the insurer receives clinical documentation from the chiropractor that the services were provided unless, within those 30 days, the insurer provides to the insured and to the chiropractor the written statement under s. 632.875 (2).

SB55-SSA1-CA1, s. 3760m Section 3760m. 632.875 (2) (intro.) of the statutes is amended to read:

SB55-SSA1-CA1,935,3 632.875 (2) (intro.) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient's coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under s. 628.46 (2m), provide to the patient and to the treating chiropractor a written statement that contains all of the following:".

SB55-SSA1-CA1,935,4 1475. Page 1181, line 12: after that line insert:

SB55-SSA1-CA1,935,5 " Section 3766r. 635.19 (6) of the statutes is repealed.".

SB55-SSA1-CA1,935,6 1476. Page 1181, line 12: after that line insert:

SB55-SSA1-CA1,935,7 " Section 3763f. 632.895 (14) (c) of the statutes is amended to read:

SB55-SSA1-CA1,935,12 632.895 (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-SSA1-CA1, s. 3763g Section 3763g. 632.895 (14) (d) 3. of the statutes is amended to read:

SB55-SSA1-CA1,935,17 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a managed care defined network plan, as defined in s. 609.01 (3c) (1b).".

SB55-SSA1-CA1,935,18 1477. Page 1181, line 12: after that line insert:

SB55-SSA1-CA1,935,19 " Section 3766e. 635.02 (2) of the statutes is amended to read:

SB55-SSA1-CA1,936,2 635.02 (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-SSA1-CA1, s. 3766ec Section 3766ec. 635.02 (3e) of the statutes is created to read: