AB652: Bill Text

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:

AB652,23,14 632.865 No prior authorization for emergency services. (1) In this section, "emergency medical condition" means a medical condition of a person that has a recent onset and that manifests itself by symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:

AB652,23,15 (a) Serious jeopardy to the person's health.

AB652,23,16 (b) Serious impairment to the person's bodily functions.

AB652,23,17 (c) Serious dysfunction of one or more of the person's body organs or parts.

AB652,23,22 (2) A health care plan, as defined in s. 628.36 (2) (a) 1., may not require prior authorization for the provision or coverage of health care items or services, including a medical screening exam and stabilizing treatment, as defined in section 1867 of the federal Social Security Act, that are provided in a hospital emergency facility for the treatment of an emergency medical condition.

AB652, s. 20 Section 20 . Nonstatutory provisions.

AB652,24,2 (1) The commissioner of insurance shall submit in proposed form the rules required under section 628.42 (5) (c) of the statutes, as created by this act, to the legislative council staff under section 227.15 (1) of the statutes no later than the first day of the 6th month beginning after the effective date of this subsection.

AB652, s. 21 Section 21 . Initial applicability.

AB652,24,11 (1) Health care plan requirements. If a contract that is affected by section 628.42 of the statutes, as created by this act, that is in effect on the first day of the 13th month beginning after publication and that was not issued or renewed after the effective date of this subsection contains terms or provisions that are inconsistent with the requirements under section 628.42 of the statutes, as created by this act, the treatment of sections 40.51 (8c) (by Section 3) and (8r) (by Section 6), 185.981 (4t) (by Section 9 ), 185.983 (1) (intro.) (by Section 12 ), 609.15 (1) (a), 609.20 (2) and (4) and 628.42 of the statutes first applies to that contract upon renewal.

AB652,24,14 (2) Point-of-service coverage option. The treatment of sections 40.51 (8c) (by Section 2) and (8r) (by Section 5 ), 185.981 (4t) (by Section 8 ), 185.983 (1) (intro.) (by Section 11) and 632.85 of the statutes first applies to all of the following:

AB652,24,16 (a) Except as provided in paragraph (b), insurance policies, plans or certificates that are issued or renewed on the effective date of this paragraph.

AB652,24,19 (b) Insurance policies, plans or certificates covering employes who are affected by a collective bargaining agreement containing provisions inconsistent with this act that are issued or renewed on the earlier of the following:

AB652,24,20 1. The day on which the collective bargaining agreement expires.

AB652,24,22 2. The day on which the collective bargaining agreement is extended, modified or renewed.

AB652,25,9 (3) Retaliatory employment termination. If a contract in existence on the effective date of this subsection between a health care plan, as defined in section 628.36 (2) (a) 1. of the statutes, and a physician, as defined in section 448.01 (5) of the statutes, or a provider, as defined in section 632.855 (1) (b) of the statutes, contains terms or provisions that are inconsistent with the prohibitions under section 632.855 of the statutes, as created by this act, the treatment of sections 40.51 (8c) (by Section 1 ) (with respect to retaliatory employment termination) and (8r) (by Section 4) (with respect to retaliatory employment termination), 185.981 (4t) (by Section 7) (with respect to retaliatory employment termination), 185.983 (1) (intro.) (by Section 10) (with respect to retaliatory employment termination) and 632.855 of the statutes first applies to that health care plan with respect to that physician or provider upon renewal of the contract.

AB652,25,14 (4) Emergency services. The treatment of sections 40.51 (8c) (by Section 1) (with respect to emergency services) and (8r) (by Section 4) (with respect to emergency services), 185.981 (4t) (by Section 7) (with respect to emergency services), 185.983 (1) (intro.) (by Section 10) (with respect to emergency services) and 632.865 of the statutes first applies to all of the following:

AB652,25,16 (a) Except as provided in paragraph (b), insurance policies, plans or certificates that are issued or renewed on the effective date of this paragraph.

AB652,25,19 (b) Insurance policies, plans or certificates covering employes who are affected by a collective bargaining agreement containing provisions inconsistent with this act that are issued or renewed on the earlier of the following:

AB652,25,20 1. The day on which the collective bargaining agreement expires.

AB652,25,22 2. The day on which the collective bargaining agreement is extended, modified or renewed.

AB652, s. 22 Section 22. Effective dates. This act takes effect on January 1, 1998, or on the day after publication, whichever is later, except as follows:

AB652,26,4 (1) Point-of-service coverage option. The treatment of sections 40.51 (8c) (by Section 2) and (8r) (by Section 5 ), 185.981 (4t) (by Section 8 ), 185.983 (1) (intro.) (by Section 11) and 632.85 of the statutes and Section 21 (2) of this act take effect on the first day of the 9th month beginning after publication.

AB652,26,9 (2) Health care plan requirements. The treatment of sections 40.51 (8c) (by Section (3) and (8r) (by Section (6 ), 185.981 (4t) (by Section (9 ), 185.983 (1) (intro.) (by Section (12), 609.15 (1) (a), 609.20 (2) and (4) and 628.42 (1), (2), (3), (4) (a) and (5) (b) of the statutes takes effect on the first day of the 13th month beginning after publication.

AB652,26,10 (End)