AB75-SSA1,1609,5
1632.835 (2) (a) Every insurer that issues a health benefit plan shall establish
2an independent review procedure whereby an insured under the health benefit plan,
3or his or her authorized representative, may request and obtain an independent
4review of an adverse determination or an experimental treatment a coverage denial
5determination made with respect to the insured.
AB75-SSA1, s. 3182 6Section 3182. 632.835 (2) (b) of the statutes is amended to read:
AB75-SSA1,1609,147 632.835 (2) (b) If an adverse determination or an experimental treatment a
8coverage denial
determination is made, the insurer involved in the determination
9shall provide notice to the insured of the insured's right to obtain the independent
10review required under this section, how to request the review, and the time within
11which the review must be requested. The notice shall include a current listing of
12independent review organizations certified under sub. (4). An independent review
13under this section may be conducted only by an independent review organization
14certified under sub. (4) and selected by the insured.
AB75-SSA1, s. 3183 15Section 3183. 632.835 (2) (bg) 3. of the statutes is amended to read:
AB75-SSA1,1609,2516 632.835 (2) (bg) 3. For any adverse determination or experimental treatment
17coverage denial determination for which an explanation of benefits is not provided
18to the insured, the insurer provides a notice that the insured may have a right to an
19independent review after the internal grievance process and that an insured may be
20entitled to expedited, independent review with respect to an urgent matter. The
21notice shall also include a reference to the section of the policy or certificate that
22contains the description of the independent review procedure as required under
23subd. 1. The notice shall provide a toll-free telephone number and website, if
24appropriate, where consumers may obtain additional information regarding
25internal grievance and independent review processes.
AB75-SSA1, s. 3184
1Section 3184. 632.835 (2) (c) of the statutes is amended to read:
AB75-SSA1,1610,72 632.835 (2) (c) Except as provided in par. (d), an insured must exhaust the
3internal grievance procedure under s. 632.83 before the insured may request an
4independent review under this section. Except as provided in sub. (9) (a), an insured
5who uses the internal grievance procedure must request an independent review as
6provided in sub. (3) (a) within 4 months after the insured receives notice of the
7disposition of his or her grievance under s. 632.83 (3) (d).
AB75-SSA1, s. 3185 8Section 3185. 632.835 (2) (e) of the statutes is created to read:
AB75-SSA1,1610,109 632.835 (2) (e) Nothing in this section affects an insured's right to commence
10a civil proceeding relating to a coverage denial determination.
AB75-SSA1, s. 3186 11Section 3186. 632.835 (3) (a) of the statutes is amended to read:
AB75-SSA1,1610,2412 632.835 (3) (a) To request an independent review, an insured or his or her
13authorized representative shall provide timely written notice of the request for
14independent review, and of the independent review organization selected, to the
15insurer that made or on whose behalf was made the adverse or experimental
16treatment
coverage denial determination. The insurer shall immediately notify the
17commissioner and the independent review organization selected by the insured of
18the request for independent review. The insured or his or her authorized
19representative must pay a $25 fee to the independent review organization. If the
20insured prevails on the review, in whole or in part, the entire amount paid by the
21insured or his or her authorized representative shall be refunded by the insurer to
22the insured or his or her authorized representative.
For each independent review in
23which it is involved, an insurer shall pay a fee to the independent review
24organization.
AB75-SSA1, s. 3187 25Section 3187. 632.835 (3) (e) of the statutes is amended to read:
AB75-SSA1,1611,11
1632.835 (3) (e) In addition to the information under pars. (b) and (c), the
2independent review organization may accept for consideration any typed or printed,
3verifiable medical or scientific evidence that the independent review organization
4determines is relevant, regardless of whether the evidence has been submitted for
5consideration at any time previously. The insurer and the insured shall submit to
6the other party to the independent review any information submitted to the
7independent review organization under this paragraph and pars. (b) and (c). If, on
8the basis of any additional information, the insurer reconsiders the insured's
9grievance and determines that the treatment that was the subject of the grievance
10should be covered, or that the policy or certificate that was rescinded should be
11reinstated,
the independent review is terminated.
AB75-SSA1, s. 3188 12Section 3188. 632.835 (3) (f) of the statutes is renumbered 632.835 (3) (f) 1.
13and amended to read:
AB75-SSA1,1611,2114 632.835 (3) (f) 1. If the independent review is not terminated under par. (e), the
15independent review organization shall, within 30 business days after the expiration
16of all time limits that apply in the matter, make a decision on the basis of the
17documents and information submitted under this subsection. The decision shall be
18in writing, signed on behalf of the independent review organization and served by
19personal delivery or by mailing a copy to the insured or his or her authorized
20representative and to the insurer. A Except as provided in subd. 2., a decision of an
21independent review organization is binding on the insured and the insurer.
AB75-SSA1, s. 3189 22Section 3189. 632.835 (3) (f) 2. of the statutes is created to read:
AB75-SSA1,1611,2523 632.835 (3) (f) 2. A decision of an independent review organization regarding
24a preexisting condition exclusion denial determination or a rescission is not binding
25on the insured.
AB75-SSA1, s. 3190
1Section 3190. 632.835 (3m) (a) of the statutes is amended to read:
AB75-SSA1,1612,52 632.835 (3m) (a) A decision of an independent review organization regarding
3an adverse determination or a preexisting condition exclusion denial determination
4must be consistent with the terms of the health benefit plan under which the adverse
5determination or preexisting condition exclusion denial determination was made.
AB75-SSA1, s. 3192 6Section 3192. 632.835 (7) (b) of the statutes is amended to read:
AB75-SSA1,1612,117 632.835 (7) (b) A health benefit plan that is the subject of an independent
8review and the insurer that issued the health benefit plan shall not be liable to any
9person for damages attributable to the insurer's or plan's actions taken in compliance
10with any decision regarding an adverse determination or an experimental treatment
11determination
rendered by a certified independent review organization.
AB75-SSA1, s. 3193 12Section 3193. 632.835 (8) of the statutes is renumbered 632.835 (8) (a) and
13amended to read:
AB75-SSA1,1612,2214 632.835 (8) (a) Adverse and experimental treatment determinations. The
15commissioner shall make a determination that at least one independent review
16organization has been certified under sub. (4) that is able to effectively provide the
17independent reviews required under this section for adverse determinations and
18experimental treatment determinations
and shall publish a notice in the Wisconsin
19Administrative Register that states a date that is 2 months after the commissioner
20makes that determination. The date stated in the notice shall be the date on which
21the independent review procedure under this section begins operating with respect
22to adverse determinations and experimental treatment determinations
.
AB75-SSA1, s. 3194 23Section 3194. 632.835 (8) (b) of the statutes is created to read:
AB75-SSA1,1613,724 632.835 (8) (b) Preexisting condition exclusion denials and rescissions. The
25commissioner shall make a determination that at least one independent review

1organization has been certified under sub. (4) that is able to effectively provide the
2independent reviews required under this section for preexisting condition exclusion
3denial determinations and rescissions and shall publish a notice in the Wisconsin
4Administrative Register that states a date that is 2 months after the commissioner
5makes that determination. The date stated in the notice shall be the date on which
6the independent review procedure under this section begins operating with respect
7to preexisting condition exclusion denial determinations and rescissions.
AB75-SSA1, s. 3195 8Section 3195. 632.835 (9) of the statutes is renumbered 632.835 (9) (a) and
9amended to read:
AB75-SSA1,1613,1810 632.835 (9) (a) Adverse and experimental treatment determinations. The
11independent review required under this section with respect to an adverse
12determination or an experimental treatment determination
shall be available to an
13insured who receives notice of the disposition of his or her grievance under s. 632.83
14(3) (d) on or after December 1, 2000. Notwithstanding sub. (2) (c), an insured who
15receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or
16after December 1, 2000, but before June 15, 2002, with respect to an adverse
17determination or an experimental treatment determination
must request an
18independent review no later than 4 months after June 15, 2002.
AB75-SSA1, s. 3196 19Section 3196. 632.835 (9) (b) of the statutes is created to read:
AB75-SSA1,1613,2520 632.835 (9) (b) Preexisting condition exclusion denials and rescissions. The
21independent review required under this section with respect to a preexisting
22condition exclusion denial determination or a rescission shall be available to an
23insured who receives notice of the disposition of his or her grievance under s. 632.83
24(3) (d) on or after the date stated in the notice published in the Wisconsin
25Administrative Register by the commissioner under sub. (8) (b).
AB75-SSA1, s. 3197
1Section 3197. 632.845 of the statutes is created to read:
AB75-SSA1,1614,4 2632.845 Prohibiting refusal to cover services because liability policy
3may cover.
(1) In this section, "health care plan" has the meaning given in s. 628.36
4(2) (a) 1.
AB75-SSA1,1614,8 5(2) An insurer that provides coverage under a health care plan may not refuse
6to cover health care services that are provided to an insured under the plan and for
7which there is coverage under the plan on the basis that there may be coverage for
8the services under a liability insurance policy.
AB75-SSA1, s. 3197n 9Section 3197n. 632.87 (4) of the statutes is amended to read:
AB75-SSA1,1614,1410 632.87 (4) No policy, plan or contract may exclude coverage for diagnosis and
11treatment of a condition or complaint by a licensed dentist within the scope of the
12dentist's license, if the policy, plan or contract covers diagnosis and treatment of the
13condition or complaint by another health care provider, as defined in s. 146.81 (1) (a)
14to (p)
.
AB75-SSA1, s. 3197r 15Section 3197r. 632.89 (1) (dm) of the statutes is created to read:
AB75-SSA1,1614,1816 632.89 (1) (dm) "Licensed mental health professional" means a clinical social
17worker who is licensed under ch. 457, a marriage and family therapist who is licensed
18under s. 457.10, or a professional counselor who is licensed under s. 457.12.
AB75-SSA1, s. 3197s 19Section 3197s. 632.89 (1) (e) 3. of the statutes is repealed and recreated to
20read:
AB75-SSA1,1614,2121 632.89 (1) (e) 3. A psychologist licensed under ch. 455.
AB75-SSA1, s. 3197t 22Section 3197t. 632.89 (1) (e) 4. of the statutes is created to read:
AB75-SSA1,1614,2423 632.89 (1) (e) 4. A licensed mental health professional practicing within the
24scope of his or her license under ch. 457 and applicable rules.
AB75-SSA1, s. 3197w 25Section 3197w. 632.895 (12m) of the statutes is created to read:
AB75-SSA1,1615,2
1632.895 (12m) Treatment for autism spectrum disorders. (a) In this
2subsection:
AB75-SSA1,1615,33 1. "Autism spectrum disorder" means any of the following:
AB75-SSA1,1615,44 a. Autism disorder.
AB75-SSA1,1615,55 b. Asperger's syndrome.
AB75-SSA1,1615,66 c. Pervasive developmental disorder not otherwise specified.
AB75-SSA1,1615,87 2. "Insured" includes an enrollee and a dependent with coverage under the
8disability insurance policy or self-insured health plan.
AB75-SSA1,1615,119 3. "Intensive-level services" means evidence-based behavioral therapy that is
10designed to help an individual with autism spectrum disorder overcome the
11cognitive, social, and behavioral deficits associated with that disorder.
AB75-SSA1,1615,1612 4. "Nonintensive-level services" means therapy that occurs after the
13completion of treatment with intensive-level services and that is designed to sustain
14and maximize gains made during treatment with intensive-level services or, for an
15individual who has not and will not receive intensive-level services, therapy that
16will improve the individual's condition.
AB75-SSA1,1615,1717 5. "Physician" has the meaning given in s. 146.34 (1) (g).
AB75-SSA1,1615,2318 (b) Subject to pars. (c) and (d), and except as provided in par. (e), every disability
19insurance policy, and every self-insured health plan of the state or a county, city,
20town, village, or school district, shall provide coverage for an insured of treatment
21for the mental health condition of autism spectrum disorder if the treatment is
22prescribed by a physician and provided by any of the following who are qualified to
23provide intensive-level services or nonintensive-level services:
AB75-SSA1,1615,2424 1. A psychiatrist, as defined in s. 146.34 (1) (h).
AB75-SSA1,1615,2525 2. A person who practices psychology, as described in s. 455.01 (5).
AB75-SSA1,1616,2
13. A social worker, as defined in s. 252.15 (1) (er), who is certified or licensed
2to practice psychotherapy, as defined in s. 457.01 (8m).
AB75-SSA1,1616,43 4. A paraprofessional working under the supervision of a provider listed under
4subds. 1. to 3.
AB75-SSA1,1616,65 5. A professional working under the supervision of an outpatient mental health
6clinic certified under s. 51.038.
AB75-SSA1,1616,77 6. A speech-language pathologist, as defined in s. 459.20 (4).
AB75-SSA1,1616,88 7. An occupational therapist, as defined in s. 448.96 (4).
AB75-SSA1,1616,179 (c) 1. The coverage required under par. (b) shall provide at least $60,000 for
10intensive-level services per insured per year, with a minimum of 30 to 35 hours of
11care per week for a minimum duration of 4 years, and at least $30,000 for
12nonintensive-level services per insured per year, except that these minimum
13coverage monetary amounts shall be adjusted annually, beginning in 2011, to reflect
14changes in the consumer price index for all urban consumers, U.S. city average, for
15the medical care group, as determined by the U.S. department of labor. The
16commissioner shall publish the new minimum coverage amounts under this
17subdivision each year, beginning in 2011, in the Wisconsin Administrative Register.
AB75-SSA1,1616,2118 2. Notwithstanding subd. 1., the minimum coverage monetary amounts or
19duration required for treatment under subd. 1., need not be met if it is determined
20by a supervising professional, in consultation with the insured's physician, that less
21treatment is medically appropriate.
AB75-SSA1,1616,2522 (d) The coverage required under par. (b) may be subject to deductibles,
23coinsurance, or copayments that generally apply to other conditions covered under
24the policy or plan. The coverage may not be subject to limitations or exclusions,
25including limitations on the number of treatment visits.
AB75-SSA1,1616,26
1(e) This subsection does not apply to any of the following:
AB75-SSA1,1617,22 1. A disability insurance policy that covers only certain specified diseases.
AB75-SSA1,1617,53 2. A health care plan offered by a limited service health organization, as defined
4in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not
5a defined network plan, as defined in s. 609.01 (1b).
AB75-SSA1,1617,66 3. A long-term care insurance policy.
AB75-SSA1,1617,77 4. A medicare replacement policy or a medicare supplement policy.
AB75-SSA1,1617,128 (f) 1. The commissioner shall by rule further define "intensive-level services"
9and "nonintensive-level services" and define "paraprofessional" for purposes of par.
10(b) 4. and "qualified" for purposes of providing services under this subsection. The
11commissioner may promulgate rules governing the interpretation or administration
12of this subsection.
AB75-SSA1,1617,2013 2. Using the procedure under s. 227.24, the commissioner may promulgate the
14rules under subd. 1. for the period before the effective date of the permanent rules
15promulgated under subd. 1., but not to exceed the period authorized under s. 227.24
16(1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the commissioner
17is not required to provide evidence that promulgating a rule under this subdivision
18as an emergency rule is necessary for the preservation of the public peace, health,
19safety, or welfare and is not required to provide a finding of emergency for a rule
20promulgated under this subdivision.
AB75-SSA1, s. 3198 21Section 3198. 632.895 (14m) of the statutes is created to read:
AB75-SSA1,1617,2522 632.895 (14m) Coverage of dependents. (a) Subject to par. (b), every disability
23insurance policy, and every self-insured health plan of the state or a county, city,
24town, village, or school district, that provides coverage for a person as a dependent
25of an insured shall provide dependent coverage for a child of an insured.
AB75-SSA1,1618,2
1(b) A policy or plan is not required to provide dependent coverage for a child of
2an insured if any of the following applies:
AB75-SSA1,1618,33 1. The child is 27 years of age or older.
AB75-SSA1,1618,44 2. The child is married.
AB75-SSA1,1618,55 3. The child has other health care coverage.
AB75-SSA1,1618,76 4. The child is employed full time and his or her employer offers health care
7coverage to its employees.
AB75-SSA1,1618,98 5. Coverage of the insured through whom the child has dependent coverage
9under the policy or plan is discontinued or not renewed.
AB75-SSA1, s. 3198d 10Section 3198d. 632.895 (17) of the statutes is created to read:
AB75-SSA1,1618,1311 632.895 (17) Contraceptives and services. (a) In this subsection,
12"contraceptives" means drugs or devices approved by the federal food and drug
13administration to prevent pregnancy.
AB75-SSA1,1618,1714 (b) Every disability insurance policy, and every self-insured health plan of the
15state or of a county, city, town, village, or school district, that provides coverage of
16outpatient health care services, preventive treatments and services, or prescription
17drugs and devices shall provide coverage for all of the following:
AB75-SSA1,1618,1918 1. Contraceptives prescribed by a health care provider, as defined in s. 146.81
19(1).
AB75-SSA1,1618,2220 2. Outpatient consultations, examinations, procedures, and medical services
21that are necessary to prescribe, administer, maintain, or remove a contraceptive, if
22covered for any other drug benefits under the policy or plan.
AB75-SSA1,1619,223 (c) Coverage under par. (b) may be subject only to the exclusions, limitations,
24or cost-sharing provisions that apply generally to the coverage of outpatient health

1care services, preventive treatments and services, or prescription drugs and devices
2that is provided under the policy or self-insured health plan.
AB75-SSA1,1619,33 (d) This subsection does not apply to any of the following:
AB75-SSA1,1619,44 1. A disability insurance policy that covers only certain specified diseases.
AB75-SSA1,1619,75 2. A disability insurance policy, or a self-insured health plan of the state or a
6county, city, town, village, or school district, that provides only limited-scope dental
7or vision benefits.
AB75-SSA1,1619,108 3. A health care plan offered by a limited service health organization, as defined
9in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not
10a defined network plan, as defined in s. 609.01 (1b).
AB75-SSA1,1619,1111 4. A long-term care insurance policy.
AB75-SSA1,1619,1212 5. A Medicare replacement policy or a Medicare supplement policy.
AB75-SSA1, s. 3199 13Section 3199. Chapter 648 of the statutes is created to read:
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