AB652: Bill Text

1. Establish standards for enrollee access to specified types of providers and health care services.

2. Provide coverage for all drugs and devices that are approved by the federal food and drug administration and allow an enrollee's attending physician to determine the appropriate drug for the enrollee's needs.

3. Develop a written policy on continuity of care and provide at least 30 days' notice to an enrollee if a provider who has been treating the enrollee terminates participation with the health care plan.

4. Establish a physician advisory committee for various specified purposes, including providing advice on the plan's medical policies and conducting peer review activities.

5. Establish procedures for fairly and systematically soliciting and acting on physician applications for participation in the plan and make the criteria for physician selection for participation in the plan available to physician applicants and the public.

6. Provide a physician with a written statement of reasons and an opportunity for a hearing prior to any restriction or termination of the physician's participation in the plan.

Under the bill, a health care plan must limit physician participation in the plan to 2-year periods. A participating physician must submit an application to continue participation in the plan and the plan must use the same criteria for continued participation that it used for initial participation.

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, alternatives to or risks associated with treatment being provided to the enrollee. The bill prohibits a health care plan from offering payment to a physician as an inducement to reduce or limit medically appropriate services.

The bill requires a health care plan to respond to a request for nonemergency services within 2 business days after the request is received. Emergency care must be provided without prior authorization.

The bill requires a health care plan to establish a utilization review program. Under the utilization review program, a health care plan must appoint a physician as its medical director, to be responsible for all clinical decisions made under the plan. The health care plan must contract with a reviewer to make recommendations on coverage or payment for services and on medical appropriateness of services. If services or coverage for services is denied on the basis that the treatment is or was not medically appropriate, the health care plan must provide the enrollee and provider with a statement of reasons for the denial and with instructions for appealing the decision. The plan must provide for review of the denial, first by the medical director, next by the physician advisory committee and finally by a physician who is not participating in the plan and who is determined by the plan's physician advisory committee to be qualified to evaluate the treatment that was the subject of the denial.

Under the bill, a health care plan may apply to the commissioner of insurance for certification that the health care plan is in compliance with the requirements established in the bill. The commissioner must appoint a task force made up of equal numbers of physicians, other providers, benefit managers, consumers of health care services and representatives of insurers to advise the commissioner on developing standards for the certification of health care plans.

Point-of-service coverage option

The bill requires any health care plan that controls utilization of health care services or that requires its enrollees to obtain health care services from providers who are members of the plan's provider network to offer all of its enrollees a coverage option under which an enrollee has access to and coverage of health care services that are provided by one or more providers who are not part of the plan's provider network. A health care plan must offer this point-of-service coverage option for a one-month period at least annually and may charge an additional premium for the coverage option.

Retaliatory employment termination and emergency services

The bill prohibits a health care plan from terminating an employment or contractual relationship with, or otherwise penalizing, a physician or other provider on the basis that the provider appealed a payer's decision to deny payment for a service or protested a decision, policy or practice that the provider reasonably believed impaired his or her ability to provide medically appropriate health care. The bill prohibits a health care plan from requiring prior authorization for the provision or coverage of health care services or items that are provided in a hospital emergency facility for the treatment of an emergency medical condition. An emergency medical condition is defined as a medical condition that has a recent onset and symptoms of such severity that a prudent layperson could reasonably conclude that lack of immediate medical attention will likely result in serious consequences to the person's health, bodily functions or body parts.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB652, s. 1 Section 1 . 40.51 (8c) of the statutes is created to read:

AB652,3,4 40.51 (8c) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the state under sub. (6) shall comply with ss. 632.855 and 632.865.

AB652, s. 2 Section 2 . 40.51 (8c) of the statutes, as created by 1997 Wisconsin Act .... (this act), section 1, is amended to read:

AB652,4,3 40.51 (8c) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the state under sub. (6) shall comply with ss. 632.85, 632.855 and 632.865.

AB652, s. 3 Section 3 . 40.51 (8c) of the statutes, as affected by 1997 Wisconsin Act .... (this act), sections 1 and 2, is amended to read:

AB652,4,8 40.51 (8c) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the state under sub. (6) shall comply with ss. 628.42 (1) to (3), 632.85, 632.855 and 632.865.

AB652, s. 4 Section 4 . 40.51 (8r) of the statutes is created to read:

AB652,4,12 40.51 (8r) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the group insurance board under sub. (7) shall comply with ss. 632.855 and 632.865.

AB652, s. 5 Section 5 . 40.51 (8r) of the statutes, as created by 1997 Wisconsin Act ... (this act), section 4, is amended to read:

AB652,4,17 40.51 (8r) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the group insurance board under sub. (7) shall comply with ss. 632.85, 632.855 and 632.865.

AB652, s. 6 Section 6 . 40.51 (8r) of the statutes, as affected by 1997 Wisconsin Act ... (this act), sections 4 and 5, is amended to read:

AB652,4,22 40.51 (8r) Every health care coverage plan, except for an uninsured health care coverage plan, offered by the group insurance board under sub. (7) shall comply with ss. 628.42 (1) to (3), 632.85, 632.855 and 632.865.

AB652, s. 7 Section 7 . 185.981 (4t) of the statutes, as affected by 1997 Wisconsin Act 27, section 3133m, is amended to read:

AB652,5,3 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 631.89, 632.72 (2), 632.745 to 632.749, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (10) to (13) and 632.897 (10) and chs. 149 and 155.

AB652, s. 8 Section 8 . 185.981 (4t) of the statutes, as affected by 1997 Wisconsin Act 27, section 3133m, and 1997 Wisconsin Act .... (this act), section 7, is amended to read:

AB652,5,9 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 631.89, 632.72 (2), 632.745 to 632.749, 632.85, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (10) to (13) and 632.897 (10) and chs. 149 and 155.

AB652, s. 9 Section 9 . 185.981 (4t) of the statutes, as affected by 1997 Wisconsin Act 27, section 3133m, and 1997 Wisconsin Act .... (this act), sections 7 and 8 , is amended to read:

AB652,5,16 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 628.42 (1) to (3), 631.89, 632.72 (2), 632.745 to 632.749, 632.85, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (10) to (13) and 632.897 (10) and chs. 149 and 155.

AB652, s. 10 Section 10 . 185.983 (1) (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, section 3134m, is amended to read:

AB652,5,24 185.983 (1) (intro.)  Every such voluntary nonprofit sickness care plan shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.89, 631.93, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (5) and (9) to (13), 632.896 and 632.897 (10) and chs. 609, 630, 635, 645 and 646, but the sponsoring association shall:

AB652, s. 11 Section 11 . 185.983 (1) (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, section 3134m, and 1997 Wisconsin Act .... (this act), section 10, is amended to read:

AB652,6,9 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.89, 631.93, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.85, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (5) and (9) to (13), 632.896 and 632.897 (10) and chs. 609, 630, 635, 645 and 646, but the sponsoring association shall:

AB652, s. 12 Section 12 . 185.983 (1) (intro.) of the statutes, as affected by 1997 Wisconsin Act 27, section 3134m, and 1997 Wisconsin Act ... (this act), sections 10 and 11 , is amended to read:

AB652,6,18 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 628.42 (1) to (3), 631.89, 631.93, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.85, 632.855, 632.865, 632.87 (2m), (3), (4) and (5), 632.895 (5) and (9) to (13), 632.896 and 632.897 (10) and chs. 609, 630, 635, 645 and 646, but the sponsoring association shall:

AB652, s. 13 Section 13. 609.15 (1) (a) of the statutes is amended to read:

AB652,6,23 609.15 (1) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) and s. 628.42 (3) (a) 5. and 6. for the resolution of enrolled participants' grievances with the health care plan.

AB652, s. 14 Section 14. 609.20 (2) of the statutes is amended to read:

AB652,7,3 609.20 (2) To ensure that the continuity of patient care for enrolled participants is not disrupted. The rules promulgated under this subsection shall be consistent with s. 628.42 (2) (a) 5.

AB652, s. 15 Section 15. 609.20 (4) of the statutes is amended to read:

AB652,7,12 609.20 (4) To ensure that employes offered a preferred provider plan that provides comprehensive services under s. 609.10 (1) (a) are given adequate notice of the opportunity to enroll and complete and understandable information under s. 609.10 (1) (c) concerning the differences between the preferred provider plan and the standard plan, including differences between providers available and differences resulting from special limitations or requirements imposed by an institutional provider because of its affiliation with a religious organization. The rules promulgated under this subsection shall be consistent with s. 628.42 (2) (a) 1.

AB652, s. 16 Section 16. 628.42 of the statutes is created to read:

AB652,7,15 628.42 Requirements for and certification of health care plans and utilization review programs. (1) Definitions. In this section:

AB652,7,17 (a) "Enrollee" means a person who is entitled to receive health care services under an individual or group health care plan.

AB652,7,18 (b) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB652,7,21 (c) "Participating" means, with respect to a physician or other provider, under contract with a health care plan to provide health care services, items or supplies to enrollees of the health care plan.

AB652,7,22 (d) "Physician" has the meaning given in s. 448.01 (5).

AB652,8,2 (e) "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.

AB652,8,4 (2) Requirements for health care plans. (a) A health care plan shall do all of the following:

AB652,8,9 1. Provide written information to prospective enrollees about the terms and conditions under the health care plan. The information must be presented in a standardized format to enable prospective enrollees to compare the attributes of different health care plans. The information must be presented in readable, easily understood language and must include all of the following:

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: