AB673,16,2323 4. Cost-sharing requirements.
AB673,16,2424 5. Participating providers.
AB673,17,2
1(b) A managed care plan shall collect and annually report to the commissioner
2the following data:
AB673,17,33 1. Gross outpatient and hospitalization data.
AB673,17,44 2. Enrollee clinical outcomes data.
AB673,17,65 (c) Subject to sub. (2), the information and data reported under pars. (a) and
6(b) shall be open to public inspection under ss. 19.31 to 19.39.
AB673,17,9 7(2) Confidentiality. A managed care plan shall establish written policies and
8procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical
9records and enrollee communications to ensure confidentiality.
AB673, s. 41 10Section 41. 609.38 of the statutes is created to read:
AB673,17,15 11609.38 Oversight. On an annual basis, the office shall perform audits of
12managed care plans in the state to review enrollee outcome data, enrollee service
13data and operational and other financial data. The commissioner shall by rule
14develop standards for managed care plans for compliance with the requirements
15under this chapter.
AB673, s. 42 16Section 42. 609.65 (1) (intro.) of the statutes is amended to read:
AB673,17,2517 609.65 (1) (intro.)  If an enrolled participant of a health maintenance
18organization, limited service health organization or preferred provider
enrollee of a
19managed care
plan is examined, evaluated or treated for a nervous or mental
20disorder pursuant to an emergency detention under s. 51.15, a commitment or a
21court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the
22limitations regarding selected participating providers, primary providers and
23referrals under ss. 609.01 (2) to (4) and 609.05 (3), the health maintenance
24organization, limited service health organization or preferred provider
managed
25care
plan shall do all of the following:
AB673, s. 43
1Section 43. 609.65 (1) (a) of the statutes is amended to read:
AB673,18,72 609.65 (1) (a) If the provider performing the examination, evaluation or
3treatment has a provider agreement with the health maintenance organization,
4limited service health organization or preferred provider
managed care plan which
5covers the provision of that service to the enrolled participant enrollee, make the
6service available to the enrolled participant enrollee in accordance with the terms
7of the health care plan and the provider agreement.
AB673, s. 44 8Section 44. 609.65 (1) (b) (intro.) of the statutes is amended to read:
AB673,18,169 609.65 (1) (b) (intro.) If the provider performing the examination, evaluation
10or treatment does not have a provider agreement with the health maintenance
11organization, limited service health organization or preferred provider
managed
12care
plan which covers the provision of that service to the enrolled participant
13enrollee, reimburse the provider for the examination, evaluation or treatment of the
14enrolled participant enrollee in an amount not to exceed the maximum
15reimbursement for the service under the medical assistance program under subch.
16IV of ch. 49, if any of the following applies:
AB673, s. 45 17Section 45. 609.65 (1) (b) 1. of the statutes is amended to read:
AB673,18,2218 609.65 (1) (b) 1. The service is provided pursuant to a commitment or a court
19order, except that reimbursement is not required under this subdivision if the health
20maintenance organization, limited service health organization or preferred provider

21managed care plan could have provided the service through a provider with whom
22it has a provider agreement.
AB673, s. 46 23Section 46. 609.65 (1) (b) 2. of the statutes is amended to read:
AB673,19,324 609.65 (1) (b) 2. The service is provided pursuant to an emergency detention
25under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20

1and the provider notifies the health maintenance organization, limited service
2health organization or preferred provider
managed care plan within 72 hours after
3the initial provision of the service.
AB673, s. 47 4Section 47. 609.65 (2) of the statutes is amended to read:
AB673,19,115 609.65 (2) If after receiving notice under sub. (1) (b) 2. the health maintenance
6organization, limited service health organization or preferred provider
managed
7care
plan arranges for services to be provided by a provider with whom it has a
8provider agreement, the health maintenance organization, limited service health
9organization or preferred provider
managed care plan is not required to reimburse
10a provider under sub. (1) (b) 2. for any services provided after arrangements are made
11under this subsection.
AB673, s. 48 12Section 48. 609.65 (3) of the statutes is amended to read:
AB673,19,2213 609.65 (3) A health maintenance organization, limited service health
14organization or preferred provider
managed care plan is only required to make
15available, or make reimbursement for, an examination, evaluation or treatment
16under sub. (1) to the extent that the health maintenance organization, limited
17service health organization or preferred provider
managed care plan would have
18made the medically necessary service available to the enrolled participant enrollee
19or reimbursed the provider for the service if any referrals required under s. 609.05
20(3) had been made and the service had been performed by a participating provider
21selected by the health maintenance organization, limited service health
22organization or preferred provider plan
.
AB673, s. 49 23Section 49. 609.655 (2) of the statutes is amended to read:
AB673,20,624 609.655 (2) If a policy or certificate issued by a health maintenance
25organization provides coverage of outpatient services provided to a dependent

1student, the policy or certificate shall provide coverage of outpatient services, to the
2extent and in the manner required under sub. (3), that are provided to the dependent
3student while he or she is attending a school located in this state but outside the
4geographical service area of the health maintenance organization, notwithstanding
5the limitations regarding selected participating providers, primary providers and
6referrals under ss. 609.01 (2) and 609.05 (3).
AB673, s. 50 7Section 50. 609.655 (5) (a) of the statutes is amended to read:
AB673,20,128 609.655 (5) (a) A policy or certificate issued by a health maintenance
9organization is required to provide coverage for the services specified in sub. (3) only
10to the extent that the policy or certificate would have covered the service if it had been
11provided to the dependent student by a selected participating provider within the
12geographical service area of the health maintenance organization.
AB673, s. 51 13Section 51. 609.655 (5) (b) of the statutes is amended to read:
AB673,20,1914 609.655 (5) (b) Paragraph (a) does not permit a health maintenance
15organization to reimburse a provider for less than the full cost of the services
16provided or an amount negotiated with the provider, solely because the
17reimbursement rate for the service would have been less if provided by a selected
18participating provider within the geographical service area of the health
19maintenance organization.
AB673, s. 52 20Section 52. 609.70 of the statutes is amended to read:
AB673,20,23 21609.70 Chiropractic coverage. Health maintenance organizations, limited
22service health organizations and preferred provider
Managed care plans are subject
23to s. 632.87 (3).
AB673, s. 53 24Section 53. 609.75 of the statutes is amended to read:
AB673,21,7
1609.75 Adopted children coverage. Health maintenance organizations,
2limited service health organizations and preferred provider
Managed care plans are
3subject to s. 632.896. Coverage of health care services obtained by adopted children
4and children placed for adoption may be subject to any requirements that the health
5maintenance organization, limited service health organization or preferred provider

6managed care plan imposes under s. 609.05 (2) and (3) on the coverage of health care
7services obtained by other enrolled participants enrollees.
AB673, s. 54 8Section 54. 609.80 of the statutes is amended to read:
AB673,21,13 9609.80 Coverage of mammograms. Health maintenance organizations and
10preferred provider plans are subject to s. 632.895 (8). Coverage of mammograms
11under s. 632.895 (8) may be subject to any requirements that the health maintenance
12organization or preferred provider plan imposes under s. 609.05 (2) and (3) on the
13coverage of other health care services obtained by enrolled participants enrollees.
AB673, s. 55 14Section 55. 609.81 of the statutes is amended to read:
AB673,21,18 15609.81 Coverage related to HIV infection. Health maintenance
16organizations, limited service health organizations and preferred provider
Managed
17care
plans are subject to s. 631.93. Health maintenance organizations and preferred
18provider plans are subject to s. 632.895 (9).
AB673, s. 56 19Section 56. 609.91 (1) (intro.) of the statutes is amended to read:
AB673,21,2520 609.91 (1) (title) Immunity of enrolled participants enrollees and
21policyholders.
(intro.) Except as provided in sub. (1m), an enrolled participant
22enrollee or policyholder of a health maintenance organization insurer is not liable for
23health care costs that are incurred on or after January 1, 1990, and that are covered
24under a policy or certificate issued by the health maintenance organization insurer,
25if any of the following applies:
AB673, s. 57
1Section 57. 609.91 (1) (b) 2. of the statutes is amended to read:
AB673,22,42 609.91 (1) (b) 2. Is physician services provided under a contract with the health
3maintenance organization insurer or by a selected participating provider of the
4health maintenance organization insurer.
AB673, s. 58 5Section 58. 609.91 (1) (b) 3. of the statutes is amended to read:
AB673,22,86 609.91 (1) (b) 3. Is services, equipment, supplies or drugs that are ancillary or
7incidental to services described in subd. 2. and are provided by the contracting
8provider or selected participating provider.
AB673, s. 59 9Section 59. 609.91 (1m) of the statutes is amended to read:
AB673,22,1410 609.91 (1m) Immunity of medical assistance recipients. An enrolled
11participant
enrollee, policyholder or insured under a policy issued by an insurer to
12the department of health and family services under s. 49.45 (2) (b) 2. to provide
13prepaid health care to medical assistance recipients is not liable for health care costs
14that are covered under the policy.
AB673, s. 60 15Section 60. 609.91 (2) of the statutes is amended to read:
AB673,22,2116 609.91 (2) Prohibited recovery attempts. No person may bill, charge, collect
17a deposit from, seek remuneration or compensation from, file or threaten to file with
18a credit reporting agency or have any recourse against an enrolled participant
19enrollee, policyholder or insured, or any person acting on their behalf, for health care
20costs for which the enrolled participant enrollee, policyholder or insured, or person
21acting on their behalf, is not liable under sub. (1) or (1m).
AB673, s. 61 22Section 61. 609.91 (3) of the statutes is amended to read:
AB673,23,223 609.91 (3) Deductibles, copayments and premiums. Subsections (1) to (2) do not
24affect the liability of an enrolled participant enrollee, policyholder or insured for any
25deductibles, copayments or premiums owed under the policy or certificate issued by

1the health maintenance organization insurer or by the insurer described in sub.
2(1m).
AB673, s. 62 3Section 62. 609.91 (4) (intro.) of the statutes is amended to read:
AB673,23,74 609.91 (4) (intro.) Conditions not affecting the immunity. The immunity of
5an enrolled participant enrollee, policyholder or insured for health care costs, to the
6extent of the immunity provided under this section and ss. 609.92 to 609.935, is not
7affected by any of the following:
AB673, s. 63 8Section 63. 609.91 (4) (a) of the statutes is amended to read:
AB673,23,149 609.91 (4) (a) An agreement, other than a notice of election or termination of
10election in accordance with s. 609.92 or 609.925, entered into by the provider, the
11health maintenance organization insurer, the insurer described in sub. (1m) or any
12other person, at any time, whether oral or written and whether implied or explicit,
13including an agreement that purports to hold the enrolled participant enrollee,
14policyholder or insured liable for health care costs.
AB673, s. 64 15Section 64. 609.91 (4) (b) of the statutes is amended to read:
AB673,23,2016 609.91 (4) (b) A breach of or default on an agreement by the health
17maintenance organization insurer, the insurer described in sub. (1m) or any other
18person to compensate the provider, directly or indirectly, for health care costs,
19including health care costs for which the enrolled participant enrollee, policyholder
20or insured is not liable under sub. (1) or (1m).
AB673, s. 65 21Section 65. 609.91 (4) (c) of the statutes is amended to read:
AB673,24,522 609.91 (4) (c) The insolvency of the health maintenance organization insurer
23or any person contracting with the health maintenance organization insurer or
24provider, or the commencement or the existence of conditions permitting the
25commencement of insolvency, delinquency or bankruptcy proceedings involving the

1health maintenance organization insurer or other person, including delinquency
2proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the health
3maintenance organization insurer or other person has agreed to compensate,
4directly or indirectly, the provider for health care costs for which the enrolled
5participant
enrollee or policyholder is not liable under sub. (1).
AB673, s. 66 6Section 66. 609.91 (4) (cm) of the statutes is amended to read:
AB673,24,147 609.91 (4) (cm) The insolvency of the insurer described in sub. (1m) or any
8person contracting with the insurer or provider, or the commencement or the
9existence of conditions permitting the commencement of insolvency, delinquency or
10bankruptcy proceedings involving the insurer or other person, including
11delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite
12whether the insurer or other person has agreed to compensate, directly or indirectly,
13the provider for health care costs for which the enrolled participant enrollee,
14policyholder or insured is not liable under sub. (1m).
AB673, s. 67 15Section 67. 609.91 (4) (d) of the statutes is amended to read:
AB673,24,2016 609.91 (4) (d) The inability of the provider or other person who is owed
17compensation for health care costs to obtain compensation from the health
18maintenance organization insurer, the insurer described in sub. (1m) or any other
19person for health care costs for which the enrolled participant enrollee, policyholder
20or insured is not liable under sub. (1) or (1m).
AB673, s. 68 21Section 68. 609.92 (5) of the statutes is amended to read:
AB673,25,222 609.92 (5) Provider of physician services. A provider who is not under
23contract with a health maintenance organization insurer and who is not a selected
24participating provider of a health maintenance organization insurer is not subject

1to s. 609.91 (1) (b) 2. with respect to health care costs incurred by an enrolled
2participant
enrollee of that health maintenance organization insurer.
AB673, s. 69 3Section 69. 609.94 (1) (b) of the statutes is amended to read:
AB673,25,64 609.94 (1) (b) Each selected participating provider of the health maintenance
5organization insurer, at the time that the provider becomes a selected participating
6provider.
AB673, s. 70 7Section 70. 645.69 (1) of the statutes is amended to read:
AB673,25,128 645.69 (1) A claim against a health maintenance organization insurer or an
9insurer described in s. 609.91 (1m) for health care costs, as defined in s. 609.01 (1j),
10for which an enrolled participant enrollee, as defined in s. 609.01 (1d), policyholder
11or insured of the health maintenance organization insurer or other insurer is not
12liable under ss. 609.91 to 609.935.
AB673, s. 71 13Section 71. 645.69 (2) of the statutes is amended to read:
AB673,25,1714 645.69 (2) A claim for health care costs, as defined in s. 609.01 (1j), for which
15an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a
16health maintenance organization managed care plan, as defined in s. 609.01 (3c), is
17not liable for any reason.
AB673, s. 72 18Section 72. 646.31 (1) (d) 8. of the statutes is amended to read:
AB673,25,2119 646.31 (1) (d) 8. Made for health care costs, as defined in s. 609.01 (1j), for which
20an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a
21health maintenance organization insurer is not liable under ss. 609.91 to 609.935.
AB673, s. 73 22Section 73. 646.31 (1) (d) 9. of the statutes is amended to read:
AB673,26,223 646.31 (1) (d) 9. Made for health care costs, as defined in s. 609.01 (1j), for which
24an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a

1health maintenance organization managed care plan, as defined in s. 609.01 (3c), is
2not liable for any reason.
AB673, s. 74 3Section 74 . Initial applicability.
AB673,26,74 (1) If a contract that is in effect on January 1, 1999, that is affected by this act
5and that was not issued or renewed after the effective date of this subsection contains
6terms or provisions that are inconsistent with the requirements under this act, this
7act first applies to that contract upon renewal.
AB673,26,128 (2) If a contract that is in effect on January 1, 1999, that is affected by this act
9and that is affected by a collective bargaining agreement that was not extended,
10modified or renewed after the effective date of this subsection contains terms or
11provisions that are inconsistent with this act, this act first applies to that contract
12on the earlier of the following:
AB673,26,1313 (a) The day on which the collective bargaining agreement expires.
AB673,26,1514 (b) The day on which the collective bargaining agreement is extended, modified
15or renewed.
AB673, s. 75 16Section 75. Effective dates. This act takes effect on January 1, 1999, or on
17the day after publication, whichever is later, except as follows:
AB673,26,1818 (1) Section 74 of this act takes effect on the day after publication.
AB673,26,1919 (End)
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