AB210-ASA1,12,14 8(3) "Health insurance coverage" has the meaning given in section 2791 (b) (1)
9of the Public Health Service Act (42 USC 300gg-91 (b) (1)). "Health insurance
10coverage" includes coverage issued by an insurer and insurance that is a group
11health plan, as defined in section 2791 (a) (1) of the Public Health Service Act (42
12USC 300gg-91
(a) (1)). "Health insurance coverage" does not include excepted
13benefits that are excluded under section 2722 (b) or (c) of the Public Health Service
14Act (42 USC 300gg-21 (b) or (c)).
AB210-ASA1,12,17 15(4) "Individual health insurance coverage" means health insurance coverage
16offered to individuals in the individual market. "Individual health insurance
17coverage" does not include short-term limited duration insurance.
AB210-ASA1,12,19 18(5) "Individual market" has the meaning given in section 1304 (a) (2) of the
19Patient Protection and Affordable Care Act.
AB210-ASA1,12,23 20(6) "Limited-scope dental or vision benefits" means limited-scope dental or
21vision benefits provided under a separate policy, certificate, or contract of insurance
22or plan, or otherwise not provided as an integral part of the policy, certificate, or
23contract of insurance or plan.
AB210-ASA1,13,3
1(7) "Patient Protection and Affordable Care Act" means the federal Patient
2Protection and Affordable Care Act, P.L. 111-148, as amended by the federal Health
3Care and Education Reconciliation Act of 2010, P.L. 111-152.
AB210-ASA1,13,7 4(8) "Preexisting condition exclusion denial determination" means a
5determination by or on behalf of an insurer that issues a health benefit plan denying
6or terminating treatment or payment for treatment on the basis of a preexisting
7condition exclusion, as defined in s. 632.745 (23).
AB210-ASA1,13,10 8(9) "Public Health Service Act" means the federal Public Health Service Act of
91944, as amended, including by the Patient Protection and Affordable Care Act (42
10USC 300gg
et seq.).
AB210-ASA1,13,12 11(10) "Secretary" means the secretary of the federal department of health and
12human services.
AB210-ASA1,13,14 13(11) "Self-insured governmental health plan" means a self-insured health
14plan of the state or a county, city, village, town, or school district.
AB210-ASA1,13,22 15(12) "Small employer health insurance" means health insurance coverage
16offered in the small group market as defined in section 2791 (e) (5) of the Public
17Health Service Act (42 USC 300gg-91 (e) (5)) and section 1304 (a) (3) of the Patient
18Protection and Affordable Care Act, as applied by the secretary's regulation for the
19purposes of section 2718 of the Public Health Service Act (42 USC 300gg-18). For
20purposes of this definition, in section 1304 (a) (3) of the Patient Protection and
21Affordable Care Act, "small employer" has the meaning given in section 1304 (b) (2)
22of that act.
AB210-ASA1,14,3 23636.10 General provisions. (1) Authority is additional. The
24commissioner's authority under this chapter is in addition to any authority
25otherwise provided under chs. 600 to 635 and chs. 644 to 646. The commissioner may

1by rule establish standards for compliance with this chapter. The commissioner may
2establish reporting requirements for the purpose of monitoring or enforcing
3compliance with this chapter and rules adopted under this chapter.
AB210-ASA1,14,8 4(2) Emergency rule-making. Using the procedure under s. 227.24, the
5commissioner may promulgate any rule under this chapter or under s. 625.03 (1m)
6(e) 2. or 3. or 625.13 (3) as an emergency rule. Notwithstanding s. 227.24 (1) (c), any
7emergency rule promulgated under this subsection may remain in effect for up to one
8year and, in addition, may be extended under s. 227.24 (2).
AB210-ASA1,14,14 9(3) Employer size election. Notwithstanding s. 636.01 (12), this state reserves
10the right to elect through legislation, as permitted under section 1304 (b) (3) of the
11Patient Protection and Affordable Care Act, to substitute "51 employees" for "101
12employees" and "50 employees" for "100 employees," after the effective date of this
13subsection .... [LRB inserts date], for any purpose permitted under the Public Health
14Service Act.
AB210-ASA1,14,17 15636.12 Internal and external appeals. (1) Establishing standards.
16Notwithstanding any inconsistent provision of chs. 600 to 635 or chs. 644 to 646, the
17commissioner shall by rule do all of the following:
AB210-ASA1,14,2218 (a) Establish standards for internal appeals that, at a minimum, include
19consumer protections consistent with section 2719 (a) of the Public Health Service
20Act (42 USC 300gg-19 (a)), and require an insurer to comply with the standards. The
21commissioner shall apply the standards established under this paragraph to all of
22the following:
AB210-ASA1,14,2423 1. Group and individual health insurance coverage subject to section 2719 (a)
24of the Public Health Service Act (42 USC 300gg-19 (a)).
AB210-ASA1,15,2
12. Grandfathered health plans that otherwise would be subject to section 2719
2(a) of the Public Health Service Act (42 USC 300gg-19 (a)).
AB210-ASA1,15,43 3. A policy, certificate, or contract that provides only limited-scope dental or
4vision benefits.
AB210-ASA1,15,55 4. Coverage specified in s. 632.745 (11) (b) 10.
AB210-ASA1,15,136 (b) Establish standards for external appeals, including standards for appealing
7a preexisting condition exclusion denial determination or the rescission of a policy
8or certificate, and require an insurer to comply with the standards. The
9commissioner shall adopt standards under this paragraph that comply either with
10section 2719 (b) (1) of the Public Health Service Act (42 USC 300gg-19 (b) (1)) or with
11the standards established by the secretary under section 2719 (b) (2) of the Public
12Health Service Act (42 USC 300gg-19 (b) (2)). The commissioner shall apply the
13external appeal standards established under this paragraph to all of the following:
AB210-ASA1,15,1514 1. Group and individual health insurance coverage subject to section 2719 (b)
15of the Public Health Service Act (42 USC 300gg-19 (b)).
AB210-ASA1,15,1616 2. Grandfathered health plans.
AB210-ASA1,15,1717 3. Coverage specified in s. 632.745 (11) (b) 10.
AB210-ASA1,15,1918 4. Coverage specified in s. 632.745 (11) (b) 11., including Medicare supplement
19or replacement policies, but excluding Medicare advantage plans.
AB210-ASA1,15,2020 (c) Establish standards for independent review organizations.
AB210-ASA1,15,22 21(2) Compliance required. An insurer and an independent review organization
22shall comply with the rules promulgated under this chapter.
AB210-ASA1,16,8 23636.15 Independent review organizations. (1) Certification. (a) An
24independent review organization may not perform a review for purposes of the
25external appeals process established in accordance with standards promulgated

1under s. 636.12 (1) (b) unless the organization is certified by the commissioner.
2Unless the commissioner provides otherwise by rule, only an independent review
3organization that is accredited by a nationally recognized private accreditation
4organization may be certified under this paragraph. An independent review
5organization must demonstrate to the satisfaction of the commissioner that it is
6unbiased and does not have a conflict of interest, as defined by the commissioner by
7rule. An organization certified under this paragraph must be recertified on a
8biennial basis.
AB210-ASA1,16,139 (b) An organization applying for certification or recertification as an
10independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp)
11or (Lr). Every organization certified or recertified as an independent review
12organization shall file a report with the commissioner in accordance with rules
13promulgated under s. 636.12 (1) (c).
AB210-ASA1,16,1814 (c) An independent review organization that was certified or recertified by the
15commissioner under s. 632.835, 2009 stats., and whose certification is in effect on the
16effective date of this paragraph .... [LRB inserts date], shall be considered to have
17been certified under par. (a), and its certification shall remain in effect until the
18certification expires or it is revoked or suspended under sub. (5) or s. 227.51 (3).
AB210-ASA1,16,23 19(2) Quality assurance mechanism. An independent review organization shall
20have in operation a quality assurance mechanism to ensure the timeliness and
21quality of the independent reviews, the qualifications and independence of the
22clinical peer reviewers, and the confidentiality of the medical records and review
23materials.
AB210-ASA1,17,4 24(3) Reasonable fees. An independent review organization shall establish
25reasonable fees that it will charge for independent reviews and shall submit its fee

1schedule to the commissioner for a determination of reasonableness and for prior
2approval. An independent review organization may not change any fees approved
3by the commissioner more than once per year and shall submit any proposed fee
4changes to the commissioner for prior approval.
AB210-ASA1,17,9 5(4) Examinations and audits. The commissioner may examine, audit, or accept
6an audit of, the books and records of an independent review organization as provided
7for examination of licensees and permittees under s. 601.43 (1), (3), (4), and (5), to
8be conducted as provided in s. 601.44, and with costs to be paid as provided in s.
9601.45.
AB210-ASA1,17,19 10(5) Revocation, suspension, refusal to recertify. The commissioner may
11revoke, suspend, or limit in whole or in part the certification of an independent
12review organization, or may refuse to recertify an independent review organization,
13if the commissioner finds that the independent review organization is unqualified
14or has violated a statute, or a rule promulgated, under chs. 600 to 646 or a valid order
15of the commissioner under s. 601.41 (4), or if the independent review organization's
16methods or practices in the conduct of its business endanger, or its financial
17resources are inadequate to safeguard, the legitimate interests of consumers and the
18public. The commissioner may summarily suspend an independent review
19organization's certification under s. 227.51 (3).
AB210-ASA1,17,22 20(6) Decision is binding. Unless otherwise required by the standards under
21section 2719 (b) of the Public Health Service Act (42 USC 300gg-19 (b)), a decision
22of an independent review organization is binding on the insured and the insurer.
AB210-ASA1,18,4 23(7) Immunity from liability. (a) An independent review organization that is
24certified under this section is immune from any civil or criminal liability that may
25result because of an independent review determination made under the rules

1promulgated under this chapter. An employee, agent, or contractor of a certified
2independent review organization is immune from any civil or criminal liability for
3any act or omission done in good faith within the scope of his or her powers and duties
4under the rules promulgated under this chapter.
AB210-ASA1,18,75 (b) An insurer is not liable to any person for damages attributable to the
6insurer's actions taken in compliance with any decision regarding a determination
7rendered by a certified independent review organization.
AB210-ASA1,18,10 8(8) Insured's right to commence civil proceeding. Nothing in this section
9affects an insured's right to commence a civil proceeding relating to a matter that
10may be appealed under the standards established under s. 636.12 (1).
AB210-ASA1,18,16 11636.18 Rebate and report requirement. Subject to s. 636.35, an insurer
12offering small employer health insurance or individual health insurance coverage
13shall comply with section 2718 of the Public Health Service Act (42 USC 300gg-18)
14and shall file the report required under section 2718 (a) of that act (42 USC 300gg-18
15(a)) with the commissioner no later than the date required for filing with the
16secretary.
AB210-ASA1,18,20 17636.25 Implementing health insurance coverage provisions. Subject to
18s. 636.35, notwithstanding any inconsistent provision in chs. 600 to 635 or chs. 644
19to 646, and unless the commissioner provides otherwise by rule under s. 636.10, all
20of the following apply:
AB210-ASA1,18,22 21(1) Insurers. An insurer shall comply with all of the following provisions of the
22Public Health Service Act:
AB210-ASA1,18,2423 (a) Standards relating to benefits for mothers and newborns. Section 2725 (42
24USC 300gg-25
).
AB210-ASA1,19,2
1(b) Required coverage for reconstructive surgery following mastectomies.
2Section 2727 (42 USC 300gg-27).
AB210-ASA1,19,43 (c) Coverage of dependent students on medically necessary leave of absence.
4Section 2728 (42 USC 300gg-28).
AB210-ASA1,19,55 (d) No lifetime limit or annual limits. Section 2711 (42 USC 300gg-11).
AB210-ASA1,19,66 (e) Prohibition on rescissions. Section 2712 (42 USC 300gg-12).
AB210-ASA1,19,87 (f) Prohibition on preexisting condition exclusions for under age 19. Section
82704 (42 USC 300gg-04), but only for enrollees who are under 19 years of age.
AB210-ASA1,19,99 (g) Coverage of preventive health services. Section 2713 (42 USC 300gg-13).
AB210-ASA1,19,1010 (h) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).
AB210-ASA1,19,1111 (i) Provision of additional information. Section 2715A (42 USC 300gg-15a).
AB210-ASA1,19,1312 (j) Patient protections; choice of health care professional. Section 2719A (a) (42
13USC 300gg-19a
(a)).
AB210-ASA1,19,1714 (k) Patient protections; coverage of emergency services. Section 2719A (b) (42
15USC 300gg-19a
(b)). In addition, an insurer also shall comply with s. 632.85 and an
16insurer that provides coverage under a defined network plan also shall comply with
17s. 609.22 (6).
AB210-ASA1,19,19 18(2) Grandfathered health plans. A grandfathered health plan shall comply
19with all of the following provisions of the Public Health Service Act:
AB210-ASA1,19,2120 (a) Coverage of dependent students on medically necessary leave of absence.
21Section 2728 (42 USC 300gg-28).
AB210-ASA1,19,2322 (b) Patient protections; coverage of emergency services. Section 2719A (b) (42
23USC 300gg-19a
(b)).
AB210-ASA1,20,3
1(3) Self-insured governmental health plans. A self-insured governmental
2health plan shall comply with all of the following provisions of the Public Health
3Service Act:
AB210-ASA1,20,54 (a) Coverage of dependent students on medically necessary leave of absence.
5Section 2728 (42 USC 300gg-28).
AB210-ASA1,20,66 (b) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).
AB210-ASA1,20,97 (c) Patient protections; coverage of emergency services. Section 2719A (b) (42
8USC 300gg-19a
(b)). In addition, a self-insured governmental health plan also shall
9comply with s. 632.85.
AB210-ASA1,20,12 10(4) Additional requirements for insurers. With respect to health insurance
11coverage that is issued or renewed on or after March 23, 2012, all of the following
12apply:
AB210-ASA1,20,1413 (a) Insurers. An insurer shall comply with all of the following provisions of the
14Public Health Service Act:
AB210-ASA1,20,1615 1. `Uniform explanation of coverage documents and standardization of
16definitions.' Section 2715 (42 USC 300gg-15).
AB210-ASA1,20,17172. `Ensuring the quality of care.' Section 2717 (42 USC 300gg-17).
AB210-ASA1,20,2018 (b) Grandfathered health plans. A grandfathered health plan shall comply
19with section 2717 of the Public Health Service Act (42 USC 300gg-17), relating to
20ensuring the quality of care.
AB210-ASA1,20,25 21(5) Application of section to grandfathered health plans. In addition to
22subs. (2) and (4) (b), this section applies to a grandfathered health plan, but only with
23respect to those provisions of the Public Health Service Act referred to in this section
24that apply to a grandfathered health plan under section 1251 of the Patient
25Protection and Affordable Care Act.
AB210-ASA1,21,9
1636.35 Applicability if federal law found unconstitutional or repealed.
2(1) Unconstitutional. (a) If the Patient Protection and Affordable Care Act is found
3by a final decision of a federal court of competent jurisdiction to be unconstitutional
4in its entirety and unenforceable in this state, and if all appeals are exhausted or the
5time for appeal expires, on and after the first day of the 3rd month beginning after
6the date on which all appeals are exhausted or the time for appeal expires s. 636.10
7does not apply, any rules promulgated or requirements established under s. 636.10
8are void and may not be enforced, and insurers and self-insured governmental
9health plans are exempt from all of the following provisions:
AB210-ASA1,21,1010 1. Section 625.13 (3).
AB210-ASA1,21,1111 2. Section 636.18.
AB210-ASA1,21,1312 3. Section 636.25, except for the extension of dependent coverage requirements
13described in s. 636.25 (1) (h) and (3) (b).
AB210-ASA1,21,1514 4. Chapter 625 with respect to small employer health insurance and group and
15blanket accident and sickness insurance offered in the individual market.
AB210-ASA1,21,2116 (b) If the Patient Protection and Affordable Care Act is found by a final decision
17of a federal court of competent jurisdiction to be unconstitutional in part and
18unenforceable in part in this state, and if all appeals are exhausted or the time for
19appeal expires, on and after the first day of the 3rd month beginning after the date
20on which all appeals are exhausted or the time for appeal expires all of the following
21apply:
AB210-ASA1,22,222 1. Insurers and self-insured governmental health plans are exempt from any
23provisions of the Public Health Service Act referred to in ss. 636.18 and 636.25 that
24correspond to the provisions of the Patient Protection and Affordable Care Act that

1are found to be unconstitutional, except for the extension of dependent coverage
2requirements described in s. 636.25 (1) (h) and (3) (b).
AB210-ASA1,22,63 2. Section 636.10 does not apply with respect to the provisions described in
4subd. 1. from which insurers and self-insured governmental health plans are
5exempt, and any rules promulgated or requirements established under s. 636.10
6with respect to those provisions are void and unenforceable.
AB210-ASA1,22,9 7(2) Repealed. If any provision of the Public Health Service Act referred to in
8this chapter is repealed, on and after the date on which the repeal is effective all of
9the following apply:
AB210-ASA1,22,1310 (a) Insurers and self-insured governmental health plans are exempt from the
11provision of the Public Health Service Act referred to in this chapter that is repealed,
12except for the extension of dependent coverage requirements described in s. 636.25
13(1) (h) and (3) (b).
AB210-ASA1,22,1714 (b) Section 636.10 does not apply with respect to any provision described in par.
15(a) from which insurers and self-insured governmental health plans are exempt, and
16any rules promulgated or requirements established under s. 636.10 with respect to
17the provision are void and unenforceable.
AB210-ASA1,22,18 18(3) Inapplicability. This section does not apply after January 1, 2020.
AB210-ASA1, s. 44 19Section 44. Nonstatutory provisions.
AB210-ASA1,22,2320 (1) Establishment of health benefit exchange. Any health benefit exchange
21established in this state under section 1311 (b) of the Patient Protection and
22Affordable Care Act, as defined in section 636.01 (7) of the statutes, as created by this
23act, must be established by legislation.
AB210-ASA1, s. 45 24Section 45 . Initial applicability.
AB210-ASA1,23,6
1(1) Miscellaneous coverage requirements. The treatment of sections 40.51
2(8) (by Section 2 ) and (8m) (by Section 4 ), 49.67 (3) (am) 2. b., 66.0137 (4) (by Section
37), 111.91 (2) (n) and (nm), 111.998 (2) (n), 120.13 (2) (g) (by Section 14), 185.983 (1)
4(intro.) (by Section 16 ), 609.755, 632.76 (2) (ac) 1., 2., 3. (intro.), and 4., 632.885,
5632.895 (15) (c) (intro.), and 636.25 (1), (2), (3), and (5) of the statutes first applies
6to all of the following:
AB210-ASA1,23,97 (a) Except as provided in paragraphs (b), (c ), and (d), disability insurance
8policies that are newly issued, and self-insured governmental or school district
9health plans that are newly established on the effective date of this paragraph.
AB210-ASA1,23,1310 (b) Except as provided in paragraph (d), disability insurance policies, and
11self-insured governmental or school district health plans, that are grandfathered
12health plans, as defined in section 636.01 (2) of the statutes, as created by this act,
13that are renewed, extended, or modified on the effective date of this paragraph.
AB210-ASA1,23,1814 (c) Except as provided in paragraph (d), disability insurance policies, and
15self-insured governmental or school district health plans, covering employees who
16are affected by a collective bargaining agreement containing provisions inconsistent
17with this act that are newly issued or newly established on the earlier of the
18following:
AB210-ASA1,23,19 191. The day on which the collective bargaining agreement expires.
AB210-ASA1,23,21 202. The day on which the collective bargaining agreement is extended, modified,
21or renewed.
AB210-ASA1,24,222 (d) Disability insurance policies, and self-insured governmental or school
23district health plans, that are grandfathered health plans, as defined in section
24636.01 (2) of the statutes, as created by this act, that cover employees who are
25affected by a collective bargaining agreement containing provisions inconsistent

1with this act, and that are renewed, extended, or modified on the earlier of the
2following:
AB210-ASA1,24,3 31. The day on which the collective bargaining agreement expires.
AB210-ASA1,24,5 42. The day on which the collective bargaining agreement is extended, modified,
5or renewed.
AB210-ASA1,24,146 (2) Internal and external appeals. The treatment of sections 40.51 (8) (by
7Section 1) (with respect to internal and external review procedures), 40.51 (8m) (by
8Section 3) (with respect to internal and external review procedures), 66.0137 (4) (by
9Section 6) (with respect to internal and external review procedures), 111.91 (2) (s),
10111.998 (2) (s), 120.13 (2) (g) (by Section 13) (with respect to internal and external
11review procedures), 185.983 (1) (intro.) (by Section 15) (with respect to internal and
12external review procedures), 600.01 (2) (b), 609.655 (4) (b), 632.83, 632.835, 636.12,
13and 636.15 of the statutes first applies to appeals filed on the effective date of this
14subsection.
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