AB673: Bill Text

Analysis by the Legislative Reference Bureau

Current law contains certain requirements that apply to health maintenance organizations, preferred provider plans and limited service health organizations (managed care plans). Those requirements address when an employer must offer a standard plan in addition to a managed care plan, coverage under a managed care plan for a child who is away at school, reporting disciplinary action taken against a participating provider and a grievance procedure. This bill provides for additional requirements which, in general, benefit enrollees under managed care plans and providers that provide health care services on behalf of those plans.

The bill requires a managed care plan to ensure that enrollees have adequate access to health care services by including a sufficient number and sufficient types of primary care providers throughout the service area of the plan. The plan must cover the services of nonparticipating specialist physicians for those enrollees who have medical conditions that cannot be adequately treated by participating providers. A managed care plan must provide enrollees with 24-hour telephone access for emergency care and authorization for care. A managed care plan must cover emergency care and may not require prior authorization for such care.

A managed care plan must permit an enrollee to choose a primary provider from a diverse list of participating providers. An enrollee with special medical needs must be able to select a specialist physician as a primary provider. A managed care plan must cover 2nd opinions from participating providers and must offer a point-of-service option under which an enrollee may obtain covered services from one or more nonparticipating providers of the enrollee's choice.

A managed care plan must provide coverage for any drug or device that is approved by the federal food and drug administration, as long as it is determined to be medically appropriate and necessary by the treating physician, regardless of whether the drug or device is being used for the purpose for which approved by the federal food and drug administration. The treating physician must be able to determine the drug therapy that is appropriate for the enrollee. A managed care plan must establish a drug utilization review program for the purpose of ensuring appropriate drug therapies for enrollees.

If a managed care plan limits coverage for experimental treatment, the plan must disclose who is authorized to make a determination on limiting coverage and the criteria used to determine whether a treatment, procedure, drug or device is experimental. Whenever coverage for experimental treatment is denied, the plan must provide the enrollee with a denial letter that advises the enrollee of who made the coverage decision, the reasons for the denial, alternative treatments that would be covered under the plan and the plan's grievance and appeal procedures.

A managed care plan must establish an internal quality assurance program, a peer review process and processes for selecting participating providers and reevaluating those providers after initial acceptance into the plan. A managed care plan must appoint a physician as medical director to be responsible for the treatment policies, protocols, quality assurance activities and utilization management decisions of the plan.

A managed care plan must inform enrollees of any financial arrangement between the plan and a participating physician that operates as an incentive or bonus for restricting services. In addition, a managed care plan may not penalize or terminate the contract of a participating provider for discussing with an enrollee financial incentives under the plan. A managed care plan may not penalize or terminate the contract of a participating provider for making referrals to other participating providers or for discussing medically necessary or appropriate care with an enrollee.

Under current law, the commissioner of insurance is required to promulgate rules for preferred provider plans to ensure that enrollees are not forced to travel excessive distances to receive health care services and to ensure continuity of care for enrollees. The bill requires those rules to apply more broadly to all managed care plans.

For further information see the state and local 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:

AB673, s. 1 Section 1. 40.51 (12) of the statutes is repealed and recreated to read:

AB673,3,3 40.51 (12) Every managed care plan, as defined in s. 609.01 (3c), that is offered by the state under sub. (6) shall comply with ch. 609.

AB673, s. 2 Section 2. 40.51 (13) of the statutes is created to read:

AB673,3,6 40.51 (13) Every managed care plan, as defined in s. 609.01 (3c), that is offered by the group insurance board under sub. (7) shall comply with ch. 609.

AB673, s. 3 Section 3. 51.20 (7) (am) of the statutes is amended to read:

AB673,4,2 51.20 (7) (am) A subject individual may not be examined, evaluated or treated for a nervous or mental disorder pursuant to a court order under this subsection unless the court first attempts to determine whether the person is an enrolled participant enrollee of a health maintenance organization, limited service health organization or preferred provider plan, as defined in s. 609.01 (4), and, if so, notifies the organization or plan that the subject individual is in need of examination, evaluation or treatment for a nervous or mental disorder.

AB673, s. 4 Section 4. 601.42 (1g) (d) of the statutes is amended to read:

AB673,4,9 601.42 (1g) (d) Statements, reports, answers to questionnaires or other information, or reports, audits or certification from a certified public accountant or an actuary approved by the commissioner, relating to the extent liabilities of a health maintenance organization insurer are or will be covered liabilities, as defined in s. 609.01 (1) liabilities for health care costs for which an enrollee or policyholder of the health maintenance organization insurer is not liable to any person under s. 609.91.

AB673, s. 5 Section 5. 609.01 (1) of the statutes is repealed.

AB673, s. 6 Section 6. 609.01 (1c) of the statutes is created to read:

AB673,4,16 609.01 (1c) "Emergency medical condition" means a medical condition of a person that has a sudden 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 might result in any of the following:

AB673,4,17 (a) Serious jeopardy to the person's health.

AB673,4,18 (b) Serious impairment to the person's bodily functions.

AB673,4,19 (c) Serious dysfunction of any of the person's bodily organs or parts.

AB673, s. 7 Section 7. 609.01 (1d) of the statutes is repealed and recreated to read:

AB673,4,22 609.01 (1d) "Enrollee" means, with respect to a managed care plan, a person who is entitled to receive health care services under the plan.

AB673, s. 8 Section 8. 609.01 (1p) of the statutes is created to read:

AB673,5,2 609.01 (1p) "Health care professional" means any individual 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.

AB673, s. 9 Section 9. 609.01 (2) of the statutes is amended to read:

AB673,5,9 609.01 (2) "Health maintenance organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, comprehensive health care services performed by providers selected by the organization participating in the plan.

AB673, s. 10 Section 10. 609.01 (3) of the statutes is amended to read:

AB673,5,16 609.01 (3) "Limited service health organization" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, in consideration for predetermined periodic fixed payments, a limited range of health care services performed by providers selected by the organization participating in the plan.

AB673, s. 11 Section 11. 609.01 (3c) of the statutes is created to read:

AB673,5,19 609.01 (3c) "Managed care plan" means a health maintenance organization, limited service health organization or preferred provider plan.

AB673, s. 12 Section 12. 609.01 (3m) of the statutes is created to read:

AB673,5,23 609.01 (3m) "Participating" means, with respect to a physician or other provider, under contract with a managed care plan to provide health care services, items or supplies to enrollees of the plan.

AB673, s. 13 Section 13. 609.01 (3r) of the statutes is created to read:

AB673,5,25 609.01 (3r) "Physician" has the meaning given in s. 448.01 (5).

AB673, s. 14 Section 14. 609.01 (4) of the statutes is amended to read:

AB673,6,7 609.01 (4) "Preferred provider plan" means a health care plan offered by an organization established under ch. 185, 611, 613 or 614 or issued a certificate of authority under ch. 618 that makes available to its enrolled participants enrollees, for consideration other than predetermined periodic fixed payments, either comprehensive health care services or a limited range of health care services performed by providers selected by the organization participating in the plan.

AB673, s. 15 Section 15. 609.01 (4m) of the statutes is created to read:

AB673,6,10 609.01 (4m) "Primary care physician" means a physician specializing in family medical practice, general internal medicine, obstetrics and gynecology or pediatrics.

AB673, s. 16 Section 16. 609.01 (5) of the statutes is repealed and recreated to read:

AB673,6,13 609.01 (5) "Primary provider" means a participating health care professional who coordinates, supervises and may provide ongoing care to an enrollee.

AB673, s. 17 Section 17. 609.01 (6) of the statutes is repealed and recreated to read:

AB673,6,16 609.01 (6) "Specialist physician" means a physician who is not a primary care physician.

AB673, s. 18 Section 18. 609.01 (7) of the statutes is amended to read:

AB673,6,19 609.01 (7) "Standard plan" means a health care plan other than a health maintenance organization or a preferred provider that is not a managed care plan.

AB673, s. 19 Section 19. 609.05 (1) of the statutes is amended to read:

AB673,6,24 609.05 (1) Except as provided in subs. (2) and (3), a health maintenance organization, limited service health organization or preferred provider managed care plan shall permit its enrolled participants enrollees to choose freely among selected participating providers.

AB673, s. 20 Section 20. 609.05 (2) of the statutes is amended to read:

AB673,7,4 609.05 (2) A health care plan under sub. (1) Subject to s. 609.24 (2) and (3), a managed care plan may require an enrolled participant enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

AB673, s. 21 Section 21. 609.05 (3) of the statutes is amended to read:

AB673,7,10 609.05 (3) Except as provided in ss. 609.65 and 609.655, a health managed care plan under sub. (1) may require an enrolled participant enrollee to obtain a referral from the primary provider designated under sub. (2) to another selected participating provider prior to obtaining health care services from the other selected that participating provider.

AB673, s. 22 Section 22. 609.10 (1) (a) of the statutes is amended to read:

AB673,7,17 609.10 (1) (a) Except as provided in subs. (2) to (4), an employer that offers any of its employes a health maintenance organization or a preferred provider plan that provides comprehensive health care services shall also offer the employes a standard plan, as provided in pars. (b) and (c), that provides at least substantially equivalent coverage of health care expenses and that is not a health maintenance organization or a preferred provider plan.

AB673, s. 23 Section 23. 609.15 (1) (intro.) of the statutes is amended to read:

AB673,7,21 609.15 (1) (intro.)  Each health maintenance organization, limited service health organization and preferred provider managed care plan shall do all of the following:

AB673, s. 24 Section 24. 609.15 (1) (a) of the statutes is amended to read:

AB673,7,25 609.15 (1) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) for the resolution of enrolled participants' enrollees' grievances with the health managed care plan.

AB673, s. 25 Section 25. 609.15 (1) (b) of the statutes is amended to read:

AB673,8,4 609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).

AB673, s. 26 Section 26. 609.15 (2) (a) of the statutes is amended to read:

AB673,8,7 609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.

AB673, s. 27 Section 27. 609.15 (2) (b) of the statutes is amended to read:

AB673,8,13 609.15 (2) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrolled participant enrollee other than the grievant, if an enrolled participant enrollee is available to serve on the grievance panel.

AB673, s. 28 Section 28. 609.17 of the statutes is amended to read:

AB673,8,20 609.17 Reports of disciplinary action. Every health maintenance organization, limited service health organization and preferred provider managed care plan shall notify the medical examining board or appropriate affiliated credentialing board attached to the medical examining board of any disciplinary action taken against a selected participating provider who holds a license or certificate granted by the board or affiliated credentialing board.

AB673, s. 29 Section 29. 609.20 (intro.) of the statutes is amended to read:

AB673,8,24 609.20 Rules for preferred provider managed care plans. (intro.) The commissioner shall promulgate rules applicable to preferred provider plans relating to managed care plans for all of the following purposes:

AB673, s. 30 Section 30. 609.20 (1) of the statutes is amended to read:

AB673,9,2 609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.

AB673, s. 31 Section 31. 609.20 (2) of the statutes is amended to read:

AB673,9,5 609.20 (2) To ensure that the continuity of patient care for enrolled participants enrollees is not disrupted.

AB673, s. 32 Section 32. 609.20 (4) of the statutes is amended to read:

AB673,9,14 609.20 (4) To ensure that employes offered a health maintenance organization or 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 health maintenance organization or 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.

AB673, s. 33 Section 33. 609.22 of the statutes is created to read:

AB673,9,20 609.22 Access to personnel and facilities. (1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of primary care and specialist physicians throughout the service area of the plan to meet the anticipated needs of its enrollees and to provide its enrollees with a meaningful choice among physicians. A managed care plan shall offer all of the following:

AB673,9,21 (a) Adequate accessible acute care hospital services for all of its enrollees.

AB673,9,23 (b) An adequate number of accessible primary care physicians for all of its enrollees.

AB673,9,25 (c) Subject to sub. (2), an adequate number of accessible specialist physicians for all of its enrollees within a reasonable distance or travel time.

AB673,10,2 (d) The availability of specialty medical services, including physical therapy, occupational therapy and rehabilitation services.

AB673,10,5 (e) The availability of nonparticipating specialist physicians for enrollees whose medical conditions require services that cannot be provided by participating specialist physicians.

AB673,10,10 (2) Nonparticipating specialists. If the treatment of a specific condition requires the services of a particular type of specialist physician and a managed care plan has no participating specialist physicians of that type, the managed care plan shall provide enrollees with the specific condition with coverage for the services of nonparticipating specialist physicians of that type.

AB673,10,15 (3) Telephone access. A managed care plan shall provide telephone access to the plan for sufficient time during business and evening hours to ensure that enrollees have adequate access to routine health care services. A managed care plan shall provide 24-hour telephone access to the plan or to a participating provider for emergency care or authorization for care.

AB673,10,20 (4) Standards for appointment scheduling. A managed care plan shall establish standards for reasonable waiting times for obtaining appointments for health care services, except for emergency care. The standards shall include scheduling guidelines based on the type of health care service for which an appointment is being made.