AB652: Bill Text

AB652,8,11 a. Coverage provisions, benefits included and service or provider exclusions or limitations.

AB652,8,14 b. Premiums, deductibles, coinsurance requirements and any other financial requirements having an effect, with respect to the cost of coverage, on an enrollee or other person making payments on behalf of an enrollee.

AB652,8,16 c. Any prior authorization or other review requirements and any procedures or other services for which an enrollee may be denied coverage.

AB652,8,18 d. Any penalties imposed against providers or utilization review entities for providing or approving too many health care services.

AB652,8,21 e. Any financial arrangements or other contractual agreements with providers or utilization review entities, including financial incentives or rewards for the limitation, restriction or high utilization of health care services or pharmaceuticals.

AB652,8,25 f. Any incentives provided to providers or utilization review entities for restricting referral or treatment options, including capitation, discounted fee-for-service, arrangements with pharmaceutical companies and salary arrangements.

AB652,9,3 g. An explanation of how determinations are made, under the health care plan, of whether a service or item is covered, including services and items developed under new and emerging technology.

AB652,9,6 h. Restrictions limiting coverage to services provided by certain specified providers or facilities and information on enrollee responsibility for payment for services not covered or unavailable under the health care plan.

AB652,9,9 i. The health care plan's loss ratios, calculated according to a standard computation and reporting methodology, and a plain language explanation of what a loss ratio is.

AB652,9,11 j. Enrollee satisfaction statistics, including reenrollment percentage and stated reasons for not reenrolling.

AB652,9,14 k. Provider satisfaction statistics, including continued participation application percentage and stated reasons for not applying for continued participation.

AB652,9,15 L. Coverage, and definition, of experimental procedures.

AB652,9,16 m. Enrollee access to participation in approved clinical trials.

AB652,9,18 n. Enrollee access to medical specialists and any related referral policies or procedures.

AB652,9,19 o. Coverage, and definition, of emergency services.

AB652,9,20 p. Any special provisions or limitations applicable to mental health services.

AB652,9,21 q. Pharmaceuticals approved for use by the participating physicians.

AB652,9,24 r. A description of the grievance and appeal procedures available under the health care plan and the percentage of appeals in which the initial denial of a claim has been reversed in each of the preceding 3 years.

AB652,10,5 2. To ensure that its enrollees have reasonable access to providers within the geographic area covered by the plan and that all covered health care services are provided in a timely manner, establish standards for access to primary care physicians, specialty care, routine, urgent and emergency care and the necessary services of other providers.

AB652,10,10 3. Provide coverage to enrollees for all drugs and devices that are approved for use by the federal food and drug administration; allow an enrollee's attending physician to determine the appropriate drug that meets the enrollee's needs; and provide information to, and otherwise educate, enrollees, participating physicians and pharmacists about appropriate prescription drug use.

AB652,10,12 4. To ensure appropriate patterns of pharmaceuticals use, establish drug utilization review procedures for managing the cost of pharmaceuticals.

AB652,11,8 5. Develop a policy, and reduce it to writing, to provide for continuity of care for its enrollees. The policy shall require at least 30 days' notice of a provider's termination of participation in the health care plan to any enrollee who selected the provider or who is receiving a course of treatment that is being provided by the provider. The written policy shall address how the health care plan intends to facilitate the continuity of care for new enrollees receiving services during a current episode of care for an acute condition from a nonparticipating provider and for current enrollees when the participation of a provider selected by an enrollee, or from whom an enrollee is receiving a course of treatment, terminates. The written policy shall describe the procedures to be used by an enrollee to request a continuation of services. With respect to determining whether to continue services, the policy shall give reasonable consideration to the clinical effect that a change of provider may have on an enrollee's treatment for an acute condition. The health care plan may require any nonparticipating provider whose services are covered under its continuity-of-care policy to agree to meet the same contractual conditions and requirements that participating providers must meet. The health care plan is not required, under its continuity-of-care policy, to cover services or provide benefits not otherwise covered or provided under the terms of the health care plan or to provide continuity of care to an enrollee who is offered a point-of-service option, as defined in s. 632.85 (1) (c), or to a new enrollee who had the option to continue with his or her previous health care plan but who chose to change plans voluntarily.

AB652,11,11 6. To ensure that proper payment is made for covered services, meet all applicable state and federal statutory and regulatory requirements related to financial reserves.

AB652,12,5 7. Establish a physician advisory committee to provide advice regarding the plan's medical policies, including the range of services to be provided and the use of new technologies and procedures for providing care; to provide advice regarding the plan's utilization review program, if any; to conduct peer review activities; to hear appeals of decisions of the plan's medical director under sub. (3) (a) 5. a. and 6. a.; to make recommendations to the governing body on initial and ongoing physician participation; and to serve as liaison between the governing body and participating physicians regarding matters of mutual interest and concern. The physician advisory committee must consist of at least 5 members. All members must be physicians participating in the health care plan. Election of committee members, leadership of the committee and the governance of the committee must be determined in accordance with rules adopted by the committee, except that any participating physician must be eligible for election to the committee and the initial membership and leadership of the committee, for a period not exceeding 90 days, shall be determined by the governing body of the health care plan. The physician advisory committee must have reasonable discretion to appoint committees and in discharging its responsibilities, including the authority to adopt rules, policies and procedures, which may be subject to approval by the health care plan's governing body.

AB652,12,11 8. Establish, in consultation with the plan's physician advisory committee, procedures for fairly and systematically, consistent with the plan's business needs, capacity and objectives, soliciting and acting upon physician applications for participation in the plan. Any physician shall be allowed to apply for participation in the plan. The procedures for soliciting and acting upon physician applications shall be reviewed annually and must include all of the following:

AB652,12,19 a. Making available in writing to applicants and to the public the objective criteria used by the plan in selecting physicians for participation in the plan, including such physician criteria as education, training, background, experience, professional disposition, demonstrated competence, demonstrated quality, membership or clinical privileges at a particular hospital and membership in a particular medical group, and including such plan criteria as professional liability insurance requirements and the number of physicians in a given specialty that are needed by the plan.

AB652,12,21 b. The review of each application by physicians representing the applicant's area of medical specialty.

AB652,12,25 c. Procedures to ensure that, whenever a physician's graduate medical education is a factor in selection for participation, training programs accredited by the Accrediting Council on Graduate Medical Education or the American Osteopathic Association are given equal recognition.

AB652,13,8 d. Procedures to ensure that, whenever the economics or capacity of a physician's practice is a criterion used in selection for participation, that criterion is documented and made available to physician applicants, physicians participating in the plan and the plan's enrollees. Any such economic or capacity criterion used in selection for participation must be adjusted to reflect a physician's patient case mix, including severity of illnesses and ages of individuals who are patients of the physician, and any other features of the physician's practice that may account for costs or services utilization that is higher or lower than expected.

AB652,13,12 e. Procedures to ensure that the health care plan does not discriminate against high-risk or vulnerable individuals or individuals with expensive-to-treat, long-term or chronic medical conditions by excluding from participation physicians with practices that include a substantial number of such individuals.

AB652,13,15 f. Procedures to ensure that the health care plan does not select physicians for participation on the basis of sex, race, creed, national origin or any other factor prohibited by law.

AB652,13,19 9. Establish, in consultation with the plan's physician advisory committee, procedures to ensure fairness in processing physician applications for participation in the plan and in making decisions regarding the status of a physician's participation in the plan. The procedures must include all of the following:

AB652,13,25 a. Reasonably prompt consideration of a participation application or renewal and reasonably prompt notification to the physician of a decision regarding initial or renewed participation. A health care plan is not required to act on an incomplete application, but must inform an applicant who submits an incomplete application of the data that is missing and must afford the applicant a reasonable opportunity to provide the missing data.

AB652,14,10 b. Providing a physician with a written statement of reasons and an opportunity to respond, in writing or orally at a hearing, before the governing body of the plan makes a final decision to deny a participation application or renewal; to suspend or restrict participation in the plan for longer than 30 days; or to terminate or permanently restrict participation in the plan. If the action under consideration by the governing body is of a type that must be reported under state or federal law to the National Practitioner Data Bank or to the medical examining board, the physician's procedural rights must meet, at a minimum, the standards of fairness required under the federal Health Care Quality Improvement Act of 1986, 42 USC 11101 to 11152.

AB652,14,23 c. Providing a physician with a written statement of reasons and an opportunity to respond, in writing or orally at a hearing, before the governing body of the plan makes a final decision to terminate, deny or restrict a physician's participation in the plan on the basis of utilization of services or economic criteria. The reasons stated must include consideration and recognition of the physician's patient case mix, including severity of illnesses and ages of enrollees who are patients of the physician, and any other features of the physician's practice that may account for costs that are higher or lower than expected. In addition to an opportunity to respond, a physician must have an opportunity to enter into and complete a corrective action plan, except in cases in which there is imminent danger of harm to patient health or action by the medical examining board or another governmental entity that effectively impairs the physician's ability to practice medicine in this state.

AB652,15,7 d. Providing a physician who is subject to summary suspension or restriction of participation in the plan based on a determination of imminent danger to the health of enrollees or other individuals with the opportunity for a hearing within 14 days after the summary suspension or restriction is imposed. The summary suspension or restriction may be continued, modified or reversed at the hearing by the governing body. A summary suspension or restriction of participation may be imposed only by plan officials, including at least one member of the physician advisory committee, who are expressly authorized to do so under the terms of the plan.

AB652,15,15 10. Limit a physician's participation in the health care plan to 2-year periods. The health care plan shall require a physician who wishes to continue to participate in the health care plan to submit an application for continued participation at the end of each 2-year period. Upon submission of an application for continued participation, the health care plan shall evaluate the participating physician submitting the application according to the same criteria used at the time that application for initial participation was approved to determine whether the physician continues to qualify for participation in the plan.

AB652,15,17 11. Establish procedures to ensure compliance with all applicable state and federal laws designed to protect the confidentiality of provider and enrollee records.

AB652,15,25 (b) In addition to satisfying the requirements under par. (a), a health care plan may not prohibit or restrict a participating provider from disclosing to an enrollee any health care information that the provider determines is medically appropriate regarding the nature of, risks associated with, and alternatives to, proposed treatment or treatment being provided to the enrollee; the availability of alternative therapies, consultation or tests; the decision of the health care plan to authorize or deny coverage for services; or the process that the health care plan uses or proposes to use to authorize or deny benefits or coverage for health care services.

AB652,16,4 (c) A health care plan may not offer payment directly or indirectly to a physician or physician group as an inducement to reduce or limit medically appropriate services or pharmaceuticals or to promote high utilization of services or pharmaceuticals.

AB652,16,5 (d) A health care plan shall establish and operate a utilization review program.

AB652,16,7 (e) A health care plan may apply to the commissioner for certification under sub. (4) that the health care plan satisfies the requirements under this subsection.

AB652,16,9 (3) Requirements for utilization review programs. (a) A health care plan, with respect to its utilization review program, shall do all of the following:

AB652,16,15 1. Appoint a medical director, who is a physician, to be responsible for all clinical decisions that are based on recommendations made by the health care plan's reviewer under subd. 4., to hear appeals of decisions of the health care plan's reviewer under subds. 5. a. and 6. a. and to ensure that the medical review and other utilization practices employed under the plan's utilization review program comply with the requirements under this subsection.

AB652,16,19 2. Develop, based on sound scientific principles and in cooperation with practicing physicians and other affected providers, the screening criteria, weighing elements and computer algorithms to be used in the health care plan's utilization review program.

AB652,16,25 3. Upon request, release to enrollees, providers and health care facilities the screening criteria, weighting elements and computer algorithms used in the health care plan's utilization review process and the method by which each was developed. The health care plan may require any enrollee, provider or health care facility receiving information under this subdivision to agree to keep the information confidential.

AB652,17,8 4. Contract with a reviewer to make recommendations on coverage for services, payment for services and whether services should be provided on the basis of medical appropriateness. The reviewer must be a physician whose area of medical specialty is recognized by the American Board of Medical Specialties or the American Osteopathic Association and who is determined by the health care plan's physician advisory committee to be qualified to evaluate issues related to coverage and services. The reviewer's compensation may not be directly affected by the decisions or recommendations that he or she makes.

AB652,17,16 5. a. Provide to an enrollee and provider seeking prior authorization for treatment that is denied on the basis that the treatment is not medically appropriate a written statement of the reasons for the denial. The statement of reasons must be documented in the case record and must include a general description of the reason that prior authorization for the treatment was denied, an explanation of the enrollee's and physician's appeal rights and instructions for the enrollee and physician to appeal to the plan's medical director and thereafter to the plan's physician advisory committee.

AB652,18,2 b. Provide for final review of a denial of prior authorization for treatment on the basis that the treatment was determined to be not medically appropriate after appeals have been heard by both the plan's medical director and the plan's physician advisory committee. The review must be conducted by a person who is licensed to practice medicine in the jurisdiction in which the claim arose, who is not participating in or under contract with the health care plan, whose area of medical specialty is recognized by the American Board of Medical Specialties or the American Osteopathic Association and who is determined by the health care plan's physician advisory committee to be qualified to evaluate the proposed treatment under review. The determination on review under this subd. 5. b. shall be made in accordance with the relevant laws and regulations of the jurisdiction in which the claim arose.

AB652,18,10 6. a. Provide to an enrollee and provider submitting a claim that is denied on the basis that the treatment provided was not medically appropriate a written statement of the reasons for denying the claim. The statement of reasons must be documented in the case record and must include a general description of the reason that coverage for the treatment was denied, an explanation of the enrollee's and physician's appeal rights and instructions for the enrollee and physician to appeal to the plan's medical director and thereafter to the plan's physician advisory committee.

AB652,18,21 b. Provide for final review of a denial of a claim on the basis that the treatment provided was determined to be not medically appropriate after appeals have been heard by both the plan's medical director and the plan's physician advisory committee. The review must be conducted by a person who is licensed to practice medicine in the jurisdiction in which the claim arose, who is not participating in or under contract with the health care plan, whose area of medical specialty is recognized by the American Board of Medical Specialties or the American Osteopathic Association and who is determined by the health care plan's physician advisory committee to be qualified to evaluate the treatment under review. The determination on review under this subd. 6. b. shall be made in accordance with the relevant laws and regulations of the jurisdiction in which the claim arose.

AB652,18,24 7. Provide to an enrollee or a physician participating in the plan, upon request, the names and credentials of all individuals conducting medical appropriateness review under the plan's utilization review program.

AB652,19,2 8. Provide emergency care, including medical screening exams and stabilizing treatment, to enrollees without prior authorization.

AB652,19,5 9. Respond to a request from an enrollee or physician for prior authorization for nonemergency medical services within 2 business days after receiving the request.

AB652,19,9 10. Make available qualified personnel to respond by telephone to any inquiry about medical appropriateness, including determination of length of stay, on the same day that the inquiry is made, except that a health care plan must respond to a request for an extension of an approved length of stay within 3 hours of the request.

AB652,19,12 11. Ensure that each enrollee, upon enrollment, signs a written medical information release consent for use whenever prior authorization is a condition for the coverage of a service.

AB652,19,17 12. Treat prior approval for a service or item as approval for all purposes such that the same service or item provided again during the same course of treatment must thereafter be covered without further approval, unless the approval was obtained fraudulently or incorrect information was provided at the time that the approval was obtained.

AB652,19,19 13. Establish procedures to ensure compliance with all applicable state and federal laws designed to protect the confidentiality of provider and enrollee records.

AB652,19,22 (b) A health care plan may apply to the commissioner for certification under sub. (4) that, with respect to its utilization review program, the health care plan satisfies the requirements under this subsection.

AB652,19,25 (4) Certification, recertification and termination of certification. (a) Under procedures and according to standards established by the commissioner, the commissioner shall do all of the following:

AB652,20,1 1. Certify health care plans that satisfy the requirements under sub. (2).

AB652,20,3 2. Certify utilization review programs that satisfy the requirements under sub. (3).

AB652,20,4 3. Consider and act upon applications for certification in a timely manner.

AB652,20,6 4. Periodically review health care plans and utilization review programs that have been certified by the commissioner.

AB652,20,8 5. Every 2 years, recertify a health care plan that has been certified and that continues to satisfy the requirements under sub. (2).

AB652,20,10 6. Every 2 years, recertify a utilization review program that has been certified and that continues to satisfy the requirements under sub. (3).

AB652,20,16 7. Terminate the certification of a health care plan or utilization review program that has been certified and that no longer satisfies the requirements under sub. (2) or (3). If the commissioner determines that a health care plan or utilization review program no longer satisfies the requirements under sub. (2) or (3), the commissioner shall provide the health care plan or utilization review program with notice and an opportunity for a hearing before terminating a certification.

AB652,20,21 (b) The commissioner shall appoint a task force to advise the commissioner on developing standards for certification of satisfaction of the requirements under subs. (2) and (3). The task force shall consist of equal numbers of physicians, other providers, benefit managers, consumers of health care services and representatives of insurers.

AB652,21,2 (5) Development and revision of certification standards; rules. (a) In developing the standards for certification under sub. (4), the commissioner shall review standards in use by the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations and shall recognize the differences in organizational structure and operation of the various types of health care plans.

AB652,21,5 (b) The commissioner shall periodically review the certification standards established under sub. (4) and may revise the standards after consulting with the task force appointed under sub. (4) (b).

AB652,21,7 (c) The commissioner shall by rule specify the standardized format that health care plans must use for providing the information under sub. (2) (a) 1.

AB652, s. 17 Section 17. 632.85 of the statutes is created to read:

AB652,21,10 632.85 Point-of-service coverage options. (1) Definitions. In this section:

AB652,21,12 (a) "Enrollee" means an individual who is entitled to receive health care services under an individual or group health care plan.

AB652,21,13 (b) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB652,21,17 (c) "Point-of-service option" means a coverage option of a health care plan that provides to enrollees of the health care plan additional coverage or access to and coverage of health care services, items or supplies provided by one or more providers who are not members of the provider network of the enrollee's health care plan.

AB652,21,21 (d) "Provider" means a hospital, as defined in s. 50.33 (2), or any person who is licensed, registered, permitted or certified by the department of health and family services or the department of regulation and licensing to provide health care services, items or supplies in this state.

AB652,21,24 (e) "Provider network" means those providers who are under contract with a health care plan to provide health care services, items or supplies to enrollees of or insureds under the health care plan.

AB652,22,8 (2) Requirement to offer coverage option. A health care plan that requires its enrollees to obtain health care services, items or supplies from providers who are members of the plan's provider network or that controls utilization of health care services shall offer to all of its enrollees, for a one-month period at least once annually, the opportunity to select a point-of-service option. In addition, the health care plan shall offer this opportunity to every enrollee who obtains coverage under the health care plan on or after the effective date of this subsection .... [revisor inserts date], when the enrollee obtains coverage under the health care plan.

AB652,22,12 (3) Premiums. A health care plan may charge an enrollee who selects a point-of-service option an additional premium for the coverage. The additional premium may not exceed the actuarial value of the enrollee's coverage under the point-of-service option.

AB652,22,15 (4) Coinsurance. A health care plan may require the payment of coinsurance for health care services, items and supplies covered by the point-of-service option. Such coinsurance may not exceed 20% of the cost of a service, item or supply.

AB652, s. 18 Section 18. 632.855 of the statutes is created to read:

AB652,22,18 632.855 Prohibition against retaliatory employment termination. (1) In this section:

AB652,22,19 (a) "Physician" has the meaning given in s. 448.01 (5).

AB652,22,23 (b) "Provider" means a hospital, as defined in s. 50.33 (2), or any person who is licensed, registered, permitted or certified by the department of health and family services or the department of regulation and licensing to provide health care services, items or supplies in this state.

AB652,23,2 (2) No health care plan, as defined in s. 628.36 (2) (a) 1., may terminate an employment or contractual relationship with a physician or other provider, or otherwise penalize a physician or other provider, principally on the basis of any of the following:

AB652,23,4 (a) That the physician or other provider, under an established grievance or appeal procedure, appealed a payer's decision to deny payment for a service.

AB652,23,7 (b) That the physician or other provider protested a decision, policy or practice that the physician or other provider reasonably believed impaired his or her ability to provide medically appropriate health care to his or her patients.

AB652, s. 19 Section 19. 632.865 of the statutes is created to read: