Amendment SSA1-AB75

AB75-SSA1,1618,4 2. The child is married.

AB75-SSA1,1618,5 3. The child has other health care coverage.

AB75-SSA1,1618,7 4. The child is employed full time and his or her employer offers health care coverage to its employees.

AB75-SSA1,1618,9 5. Coverage of the insured through whom the child has dependent coverage under the policy or plan is discontinued or not renewed.

AB75-SSA1, s. 3198d Section 3198d. 632.895 (17) of the statutes is created to read:

AB75-SSA1,1618,13 632.895 (17) Contraceptives and services. (a) In this subsection, "contraceptives" means drugs or devices approved by the federal food and drug administration to prevent pregnancy.

AB75-SSA1,1618,17 (b) Every disability insurance policy, and every self-insured health plan of the state or of a county, city, town, village, or school district, that provides coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices shall provide coverage for all of the following:

AB75-SSA1,1618,19 1. Contraceptives prescribed by a health care provider, as defined in s. 146.81 (1).

AB75-SSA1,1618,22 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan.

AB75-SSA1,1619,2 (c) Coverage under par. (b) may be subject only to the exclusions, limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan.

AB75-SSA1,1619,3 (d) This subsection does not apply to any of the following:

AB75-SSA1,1619,4 1. A disability insurance policy that covers only certain specified diseases.

AB75-SSA1,1619,7 2. A disability insurance policy, or a self-insured health plan of the state or a county, city, town, village, or school district, that provides only limited-scope dental or vision benefits.

AB75-SSA1,1619,10 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 defined network plan, as defined in s. 609.01 (1b).

AB75-SSA1,1619,11 4. A long-term care insurance policy.

AB75-SSA1,1619,12 5. A Medicare replacement policy or a Medicare supplement policy.

AB75-SSA1, s. 3199 Section 3199. Chapter 648 of the statutes is created to read:

AB75-SSA1,1619,14 CHAPTER 648

AB75-SSA1,1619,16 Regulation of Care Management Organizations

AB75-SSA1,1619,17 648.01 Definitions. In this chapter:

AB75-SSA1,1619,19 (1) "Care management organization" means an entity described in s. 46.284 (3m).

AB75-SSA1,1619,20 (2) "Department" means the department of health services.

AB75-SSA1,1619,21 (3) "Enrollee" has the meaning given in s. 46.2805 (3).

AB75-SSA1,1619,23 (4) "Permittee" means a care management organization issued a permit under this chapter.

AB75-SSA1,1619,25 648.03 Applicability of other laws. Notwithstanding s. 600.01 (1) (b) 10. a., ss. 600.01, 600.02, 600.03, and 600.12 apply to this chapter.

AB75-SSA1,1620,3 648.05 Permit. (1) Permit required. After December 31, 2009, no care management organization may provide services to its enrollees without a permit under this chapter.

AB75-SSA1,1620,5 (2) Application. A care management organization applying for a permit shall submit all of the following information in the format required by the commissioner:

AB75-SSA1,1620,8 (a) The names, addresses and occupations of all controlling persons and directors and principal officers of the care management organization currently and for the preceding 10 years, unless the commissioner waives this requirement.

AB75-SSA1,1620,10 (b) Business organization documents, including articles and bylaws if applicable.

AB75-SSA1,1620,13 (c) A business plan approved by the department, including a projection of the anticipated operating results at the end of each of the next 3 years of operation, based on reasonable estimates of income and operating expenses.

AB75-SSA1,1620,15 (d) Any other relevant documents or information that the commissioner reasonably requires after consulting with the department.

AB75-SSA1,1620,18 (3) Standards for issuing permit. The commissioner may issue a permit to the care management organization if the commissioner finds, after consulting with the department, all of the following:

AB75-SSA1,1620,19 (a) All requirements of law have been met.

AB75-SSA1,1620,23 (b) All the directors and principal officers or any controlling person are trustworthy and competent and collectively have the competence and experience to engage in the proposed services and are not excluded from participation under 42 USC 1320a-7 or 42 USC 1320a-7a.

AB75-SSA1,1620,25 (c) The business plan is consistent with the interests of the care management organization's enrollees and the public.

AB75-SSA1,1621,3 (4) Suspension or revocation. The commissioner may suspend or revoke a permit issued under this chapter if the commissioner finds, after consulting with the department, any of the following:

AB75-SSA1,1621,5 (a) The permittee violated a law or rule, including a rule establishing standards for the financial condition of care management organizations.

AB75-SSA1,1621,6 (b) The permittee is in a financially hazardous condition.

AB75-SSA1,1621,8 (c) The permittee is controlled or managed by persons who are incompetent or untrustworthy.

AB75-SSA1,1621,9 (d) The permittee conceals records from the commissioner.

AB75-SSA1,1621,10 (e) The permittee's business plan is not in the public interest or is not prudent.

AB75-SSA1,1621,12 (f) The permittee ceases to be certified by or maintain a contract with the department.

AB75-SSA1,1621,14 648.10 Powers and duties of the commissioner. The commissioner may do any of the following:

AB75-SSA1,1621,17 (1) Promulgate rules that are necessary to carry out the intent of this chapter, including, after consulting with the department, standards for the financial condition of care management organizations.

AB75-SSA1,1621,21 (2) Use the authority granted under ss. 601.41, 601.42, 601.43, 601.44, 601.61, 601.62, 601.63, and 601.64, including the authority to issue orders, to enforce this chapter and to ensure that a care management organization has sufficient financial resources.

AB75-SSA1,1621,23 648.15 Reports and replies. (1) Reports. The commissioner may require from any care management organization any of the following:

AB75-SSA1,1622,3 (a) Statements, reports, answers to questionnaires, and other information in whatever reasonable form the commissioner designates and at such reasonable intervals as the commissioner chooses, or from time to time.

AB75-SSA1,1622,5 (b) Full explanation of the programming of any data storage or communication system in use.

AB75-SSA1,1622,8 (c) Information from any books, records, electronic data processing systems, computers, or any other information storage system at any reasonable time in any reasonable manner.

AB75-SSA1,1622,10 (d) Statements, reports, audits, or certification from a certified public accountant or an actuary approved by the commissioner.

AB75-SSA1,1622,13 (2) Forms. The commissioner, after consulting with the department, may prescribe forms for the reports under sub. (1) and specify who shall execute or certify such reports.

AB75-SSA1,1622,17 (3) Accounting methods. The commissioner, after consulting with the department, may prescribe reasonable minimum standards and techniques of accounting and data handling to ensure that timely and reliable information will exist and will be available to the commissioner.

AB75-SSA1,1622,23 (4) Replies. Any officer or manager of a care management organization, any person controlling or having a contract under which the person has a right to control a care management organization, whether exclusively or otherwise, or any person with executive authority over or in charge of any segment of such a care management organization's affairs, shall reply promptly in writing or in another designated form, to any written inquiry from the commissioner requesting a reply.

AB75-SSA1,1622,25 (5) Verification. The commissioner may require that any communication made to the commissioner under this section be verified.

AB75-SSA1,1623,3 (6) Immunity. In the absence of actual malice, no person shall be subject to damages in an action for defamation based on a communication to the commissioner required by law under this chapter or by the commissioner under this chapter.

AB75-SSA1,1623,10 (7) Experts. The commissioner may employ experts to assist the commissioner in an examination or in the review of any transaction subject to approval under this chapter. The care management organization that is the subject of the examination, or that is a party to a transaction under review, including the person acquiring, controlling, or attempting to acquire the care management organization, shall pay the reasonable costs incurred by the commissioner for the expert and related expenses.

AB75-SSA1,1623,13 648.20 Examinations. (1) Power to examine. (a) To inform himself or herself about a matter related to the enforcement of this chapter, the commissioner may examine the affairs and condition of any permittee.

AB75-SSA1,1623,16 (b) So far as reasonably necessary for an examination under par. (a), the commissioner may examine the accounts, records, or documents so far as they relate to the permittee, of any of the following:

AB75-SSA1,1623,18 1. An officer, manager, employee, or person who has executive authority over or is in charge of any segment of the permittee's affairs.

AB75-SSA1,1623,20 2. A person controlling or having a contract under which the person has the right to control the permittee whether exclusively or with others.

AB75-SSA1,1623,23 3. A person who is under the control of the permittee, or a person who is under the control of a person who controls or has a right to control the permittee whether exclusively or with others.

AB75-SSA1,1624,3 (c) On demand, every permittee shall make available to the commissioner for examination any of its own accounts, records, documents, or evidences of transactions.

AB75-SSA1,1624,5 (d) On order of the commissioner any examinee under this chapter shall bring to the office for examination such records as the order reasonably requires.

AB75-SSA1,1624,12 (2) Audits or actuarial or other evaluations. In lieu of all or part of an examination under sub. (1), or in addition to it, the commissioner may order an independent audit by certified public accountants or an actuarial or other evaluation by actuaries or other experts approved by the commissioner of any permittee. Any accountant, actuary, or other expert selected is subject to rules respecting conflicts of interest promulgated by the commissioner. Any audit or evaluation under this section is subject to s. 648.25, so far as applicable.

AB75-SSA1,1624,18 (3) Alternatives to examination. In lieu of all or part of an examination under this section, the commissioner may accept the report of an audit already made by certified public accountants or of an actuarial or other evaluation already made by actuaries or other experts approved by the commissioner, or the report of an examination made by another government agency in this state, the federal government, or another state.

AB75-SSA1,1625,2 (4) Purpose and scope of examination. An examination may but need not cover comprehensively all aspects of the permittee's affairs and condition. The commissioner shall determine the exact nature and scope of each examination, and in doing so shall take into account all relevant factors, including the length of time the permittee has been doing business, the length of time the permittee has been certified by the department, the nature of the business being examined, the nature of the accounting records available, and the nature of examinations performed elsewhere.

AB75-SSA1,1625,6 648.25 Conducting examinations. (1) Order of examination. For each examination under s. 648.20, the commissioner shall issue an order stating the scope of the examination and designating the examiner in charge. Upon demand, a copy of the order shall be provided to the examinee.

AB75-SSA1,1625,9 (2) Access to examinee. Any examiner authorized by the commissioner shall, for the purposes of the examination, have access at all reasonable hours to the premises and to any property of the examinee.

AB75-SSA1,1625,13 (3) Cooperation. The officers, employees, and agents of the examinee shall comply with every reasonable request of the examiners for assistance in any matter relating to the examination. No person may obstruct or interfere with the examination in any way other than by legal process.

AB75-SSA1,1625,17 (4) Correction of books. If the commissioner finds the accounts or records to be inadequate for proper examination of the condition and affairs of the permittee or improperly kept or posted, the commissioner may employ experts to rewrite, post, or balance them at the expense of the permittee.

AB75-SSA1,1625,23 (5) Report on examination. The examiner in charge of an examination shall make a proposed report of the examination, including information and analysis ordered in sub. (1), together with the examiner's recommendations. Preparation of the proposed report may include conferences with the examinee or the examinee's representatives at the option of the examiner in charge. The commissioner shall serve the final examination report on the examinee.

AB75-SSA1,1625,25 (6) Copies for board. The permittee shall furnish copies of the final examination report to each member of its board or governing body.

AB75-SSA1,1626,7 (7) Report as evidence. In any proceeding by or against the permittee or any officer or agent of the permittee the final examination report shall be admissible as evidence of the facts stated in the report. In any proceeding commenced under this chapter, the final examination report shall be admissible as evidence of the facts stated in the report. In any proceeding by or against the examinee, the facts asserted in any final examination report properly admitted in evidence shall be presumed to be true in the absence of contrary evidence.

AB75-SSA1,1626,13 648.27 Costs. (1) Costs to be paid by care management organizations. Permittees shall pay the reasonable estimate of costs of examinations under s. 648.20, of review of applications under s. 648.05, and of analysis and financial monitoring of care management organizations by the commissioner and the department, including overhead and fixed costs, by a system of regular annual billings.

AB75-SSA1,1626,19 (2) Determination of costs. Annually, the commissioner shall determine the estimated costs under sub. (1) for the commissioner and the department. The commissioner shall serve a request for payment on each permittee allocating the cost to each permittee in an amount that the commissioner determines reflects the permittee's proportionate share of projected enrollment in the department's annual contracting period.

AB75-SSA1,1626,21 (3) Payment deadline. The permittee shall pay the amount determined by the commissioner within 30 days of service of the request for payment under sub. (2).

AB75-SSA1,1626,24 648.30 Nondisclosure of information. (1) Types of information. The office may refuse to disclose and may prevent any other person from disclosing any of the following:

AB75-SSA1,1627,2 (a) Testimony, reports, records, and information that are obtained, produced, or created in the course of an inquiry under s. 648.15.

AB75-SSA1,1627,4 (b) Testimony, reports, records, and information that are obtained, produced, or created in the course of an examination under s. 648.20.

AB75-SSA1,1627,8 (c) Testimony, reports, records, communications, and information that are obtained by the office from, or provided by the office to, any of the following, under a pledge of confidentiality or for the purpose of assisting or participating in monitoring activities or in the conduct of any inquiry, investigation, or examination:

AB75-SSA1,1627,9 1. The National Association of Insurance Commissioners.

AB75-SSA1,1627,11 2. An agent or employee of the National Association of Insurance Commissioners.

AB75-SSA1,1627,12 3. The insurance commissioner of another state.

AB75-SSA1,1627,13 4. An agent or employee of the insurance commissioner of another state.

AB75-SSA1,1627,15 5. An international, federal, state, or local regulatory or law enforcement agency, including the department.

AB75-SSA1,1627,16 6. An agent or employee of an agency described in subd. 5.

AB75-SSA1,1627,18 (2) Waiver and applicability of the privilege. Section 601.465 (2m) (a) to (d) applies to the privilege under sub. (1).

AB75-SSA1,1627,24 648.35 Enforcement procedure. (1) Injunctions and restraining orders. The commissioner may commence an action in circuit court in the name of the state to restrain by temporary or permanent injunction or by temporary restraining order any violation of this chapter, any rule promulgated under this chapter, or any order issued under s. 648.10 (2). The commissioner need not show irreparable harm or lack of an adequate remedy at law in an action commenced under this subsection.

AB75-SSA1,1628,3 (2) Orders. The commissioner shall issue any orders under the procedures described in s. 601.63 and shall hold any hearings under the procedures described in s. 601.62.