AB673,11,20 17(2) Primary providers. Except as provided in sub. (3), a managed care plan
18shall permit each enrollee to select his or her own primary provider from a list of
19participating health care professionals. The list shall be updated on an ongoing basis
20and shall include all of the following:
AB673,11,2221 (a) A sufficient number of health care professionals who are accepting new
22enrollees.
AB673,11,2523 (b) A sufficient diversity of health care professionals to adequately meet the
24needs of an enrollee population with varied characteristics, including age, gender,
25race and health status.
AB673,12,3
1(3) Specialist providers. (a) A managed care plan shall establish a system
2under which an enrollee with a chronic disease or other special needs may select a
3participating specialist physician as his or her primary provider.
AB673,12,74 (b) A managed care plan shall allow all enrollees under the plan to have access
5to specialist physicians on a timely basis when specialty medical care is warranted.
6An enrollee shall be allowed to choose among participating specialist physicians
7when a referral is made for specialty care.
AB673,12,12 8(4) Point-of-service option. A managed care plan shall offer a
9point-of-service option, under which an enrollee may obtain covered services from
10a nonparticipating provider of the enrollee's choice. Under the point-of-service
11option, the enrollee may be required to pay a reasonable portion of the cost of those
12services.
AB673,12,14 13(5) Second opinions. A managed care plan shall provide an enrollee with
14coverage for a 2nd opinion from another participating provider.
AB673, s. 35 15Section 35. 609.26 of the statutes is created to read:
AB673,12,22 16609.26 Drugs and devices. (1) Coverage. (a) A managed care plan shall
17provide coverage of any drug or device that is approved for use by the federal food and
18drug administration and that is determined by a treating participating provider to
19be medically appropriate and necessary for treatment of an enrollee's condition,
20regardless of whether the drug or device is prescribed by the treating participating
21provider for the use for which the drug or device is approved by the federal food and
22drug administration.
AB673,12,2423 (b) A treating participating provider shall determine the drug therapy that is
24appropriate for his or her patient.
AB673,13,2
1(c) Prospective review of drug therapy may deny coverage only if any of the
2following apply:
AB673,13,33 1. A coverage limitation has been reached with respect to the enrollee.
AB673,13,44 2. The enrollee has committed fraud with respect to obtaining the drug.
AB673,13,8 5(2) Drug utilization review program. (a) A managed care plan shall establish
6and operate a drug utilization review program. The primary goal of the program
7shall be to enhance quality of care for enrollees by ensuring appropriate drug
8therapy.
AB673,13,99 (b) The program under par. (a) shall include all of the following:
AB673,13,1010 1. Retrospective review of prescription drugs furnished to enrollees.
AB673,13,1211 2. Ongoing periodic examination of data on outpatient prescription drugs to
12ensure quality therapeutic outcomes for enrollees.
AB673,13,1413 3. An educational outreach program for physicians, pharmacists and enrollees
14regarding the appropriate use of prescription drugs.
AB673,13,1515 (c) The program under par. (a) shall utilize all of the following:
AB673,13,1616 1. Clinically relevant criteria and standards for drug therapy.
AB673,13,1817 2. Nonproprietary criteria and standards developed and revised through an
18open, professional consensus process.
AB673,13,1919 3. Interventions that focus on improving therapeutic outcomes.
AB673, s. 36 20Section 36. 609.28 of the statutes is created to read:
AB673,13,24 21609.28 Experimental treatment. (1) Disclosure of limitations. A
22managed care plan that limits coverage for experimental treatment shall define the
23limitation and disclose the limits in any agreement or certificate of coverage. This
24disclosure shall include the following information:
AB673,13,2525 (a) Who is authorized to make a determination on the limitation.
AB673,14,2
1(b) The criteria the plan uses to determine whether a treatment, procedure,
2drug or device is experimental.
AB673,14,7 3(2) Denial of treatment. If a managed care plan denies coverage of an
4experimental treatment, procedure, drug or device for an enrollee who has a
5terminal condition or illness, the managed care plan shall provide the enrollee with
6a denial letter within 20 working days after the request for coverage is submitted.
7The denial letter shall include all of the following:
AB673,14,88 (a) The name and title of the individual making the decision.
AB673,14,109 (b) A statement setting forth the specific medical and scientific reasons for
10denying coverage.
AB673,14,1211 (c) A description of any alternative treatment, procedures, drugs or devices
12covered by the plan.
AB673,14,1313 (d) A written copy of the plan's grievance and appeal procedure.
AB673, s. 37 14Section 37. 609.30 of the statutes is created to read:
AB673,14,18 15609.30 Provider disclosures. (1) Plan may not contract. A managed care
16plan may not contract with a participating provider to limit the provider's disclosure
17of information, to or on behalf of an enrollee, about the enrollee's medical condition
18or treatment options.
AB673,14,22 19(2) Plan may not penalize or terminate. (a) A managed care plan may not
20penalize a participating provider for discussing with an enrollee financial incentives
21offered by the plan or other financial arrangements between the plan and the
22provider.
AB673,15,323 (b) A participating provider may discuss, with or on behalf of an enrollee, all
24treatment options and any other information that the provider determines to be in
25the best interest of the enrollee. A managed care plan may not penalize or terminate

1the contract of a participating provider because the provider makes referrals to other
2participating providers or discusses medically necessary or appropriate care with or
3on behalf of an enrollee.
AB673, s. 38 4Section 38. 609.32 of the statutes is created to read:
AB673,15,8 5609.32 Quality assurance. (1) Standards. A managed care plan shall
6develop comprehensive quality assurance standards that are adequate to identify,
7evaluate and remedy problems related to access to, and continuity and quality of,
8care. The standards shall include at least all of the following:
AB673,15,99 (a) An ongoing, written internal quality assurance program.
AB673,15,1010 (b) Specific written guidelines for quality of care studies and monitoring.
AB673,15,1111 (c) Performance and clinical outcomes-based criteria.
AB673,15,1312 (d) A procedure for remedial action to address quality problems, including
13written procedures for taking appropriate corrective action.
AB673,15,1414 (e) A plan for gathering and assessing data.
AB673,15,1515 (f) A peer review process.
AB673,15,23 16(2) Selection and evaluation of providers. (a) A managed care plan shall
17develop a process for selecting participating providers, including written policies and
18procedures that the plan uses for review and approval of providers. After consulting
19with appropriately qualified providers, the plan shall establish minimum
20professional requirements for its participating providers. The process for selection
21shall include verification of a provider's license or certificate, including the history
22of any suspensions or revocations, and the history of any liability claims made
23against the provider.
AB673,16,224 (b) A managed care plan shall establish in writing a formal, ongoing process
25for reevaluating each participating provider within a specified number of years after

1the provider's initial acceptance for participation. The reevaluation shall include all
2of the following:
AB673,16,33 1. Updating the previous review criteria.
AB673,16,54 2. Assessing the provider's performance on the basis of such criteria as enrollee
5clinical outcomes, number of complaints and malpractice actions.
AB673,16,76 (c) A managed care plan may not require a participating provider to provide
7services that are outside the scope of his or her license or certificate.
AB673, s. 39 8Section 39. 609.34 of the statutes is created to read:
AB673,16,12 9609.34 Clinical decision-making. (1) Medical director. A managed care
10plan shall appoint a physician as medical director. The medical director shall be
11responsible for treatment policies, protocols, quality assurance activities and
12utilization management decisions of the plan.
AB673,16,15 13(2) Incentives. A managed care plan shall inform enrollees of any financial
14arrangement between the plan and a participating physician or pharmacist that
15includes or operates as an incentive or a bonus for restricting services.
AB673, s. 40 16Section 40. 609.36 of the statutes is created to read:
AB673,16,19 17609.36 Data systems and confidentiality. (1) Information and data
18reporting.
(a) A managed care plan shall provide to the commissioner information
19related to all of the following:
AB673,16,2020 1. The structure of the plan.
AB673,16,2121 2. The plan's decision-making process.
AB673,16,2222 3. Health care benefits and exclusions.
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.
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