AB673: Bill Text

AB673, s. 38 Section 38. 609.32 of the statutes is created to read:

AB673,15,8 609.32 Quality assurance. (1) Standards. A managed care plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following:

AB673,15,9 (a) An ongoing, written internal quality assurance program.

AB673,15,10 (b) Specific written guidelines for quality of care studies and monitoring.

AB673,15,11 (c) Performance and clinical outcomes-based criteria.

AB673,15,13 (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

AB673,15,14 (e) A plan for gathering and assessing data.

AB673,15,15 (f) A peer review process.

AB673,15,23 (2) Selection and evaluation of providers. (a) A managed care plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider's license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider.

AB673,16,2 (b) A managed care plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider's initial acceptance for participation. The reevaluation shall include all of the following:

AB673,16,3 1. Updating the previous review criteria.

AB673,16,5 2. Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

AB673,16,7 (c) A managed care plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.

AB673, s. 39 Section 39. 609.34 of the statutes is created to read:

AB673,16,12 609.34 Clinical decision-making. (1) Medical director. A managed care plan shall appoint a physician as medical director. The medical director shall be responsible for treatment policies, protocols, quality assurance activities and utilization management decisions of the plan.

AB673,16,15 (2) Incentives. A managed care plan shall inform enrollees of any financial arrangement between the plan and a participating physician or pharmacist that includes or operates as an incentive or a bonus for restricting services.

AB673, s. 40 Section 40. 609.36 of the statutes is created to read:

AB673,16,19 609.36 Data systems and confidentiality. (1) Information and data reporting. (a) A managed care plan shall provide to the commissioner information related to all of the following:

AB673,16,20 1. The structure of the plan.

AB673,16,21 2. The plan's decision-making process.

AB673,16,22 3. Health care benefits and exclusions.

AB673,16,23 4. Cost-sharing requirements.

AB673,16,24 5. Participating providers.

AB673,17,2 (b) A managed care plan shall collect and annually report to the commissioner the following data:

AB673,17,3 1. Gross outpatient and hospitalization data.

AB673,17,4 2. Enrollee clinical outcomes data.

AB673,17,6 (c) Subject to sub. (2), the information and data reported under pars. (a) and (b) shall be open to public inspection under ss. 19.31 to 19.39.

AB673,17,9 (2) Confidentiality. A managed care plan shall establish written policies and procedures, consistent with ss. 51.30, 146.82 and 252.15, for the handling of medical records and enrollee communications to ensure confidentiality.

AB673, s. 41 Section 41. 609.38 of the statutes is created to read:

AB673,17,15 609.38 Oversight. On an annual basis, the office shall perform audits of managed care plans in the state to review enrollee outcome data, enrollee service data and operational and other financial data. The commissioner shall by rule develop standards for managed care plans for compliance with the requirements under this chapter.

AB673, s. 42 Section 42. 609.65 (1) (intro.) of the statutes is amended to read:

AB673,17,25 609.65 (1) (intro.)  If an enrolled participant of a health maintenance organization, limited service health organization or preferred provider enrollee of a managed care plan is examined, evaluated or treated for a nervous or mental disorder pursuant to an emergency detention under s. 51.15, a commitment or a court order under s. 51.20 or 880.33 (4m) or (4r) or ch. 980, then, notwithstanding the limitations regarding selected participating providers, primary providers and referrals under ss. 609.01 (2) to (4) and 609.05 (3), the health maintenance organization, limited service health organization or preferred provider managed care plan shall do all of the following:

AB673, s. 43 Section 43. 609.65 (1) (a) of the statutes is amended to read:

AB673,18,7 609.65 (1) (a) If the provider performing the examination, evaluation or treatment has a provider agreement with the health maintenance organization, limited service health organization or preferred provider managed care plan which covers the provision of that service to the enrolled participant enrollee, make the service available to the enrolled participant enrollee in accordance with the terms of the health care plan and the provider agreement.

AB673, s. 44 Section 44. 609.65 (1) (b) (intro.) of the statutes is amended to read:

AB673,18,16 609.65 (1) (b) (intro.) If the provider performing the examination, evaluation or treatment does not have a provider agreement with the health maintenance organization, limited service health organization or preferred provider managed care plan which covers the provision of that service to the enrolled participant enrollee, reimburse the provider for the examination, evaluation or treatment of the enrolled participant enrollee in an amount not to exceed the maximum reimbursement for the service under the medical assistance program under subch. IV of ch. 49, if any of the following applies:

AB673, s. 45 Section 45. 609.65 (1) (b) 1. of the statutes is amended to read:

AB673,18,22 609.65 (1) (b) 1. The service is provided pursuant to a commitment or a court order, except that reimbursement is not required under this subdivision if the health maintenance organization, limited service health organization or preferred provider managed care plan could have provided the service through a provider with whom it has a provider agreement.

AB673, s. 46 Section 46. 609.65 (1) (b) 2. of the statutes is amended to read:

AB673,19,3 609.65 (1) (b) 2. The service is provided pursuant to an emergency detention under s. 51.15 or on an emergency basis to a person who is committed under s. 51.20 and the provider notifies the health maintenance organization, limited service health organization or preferred provider managed care plan within 72 hours after the initial provision of the service.

AB673, s. 47 Section 47. 609.65 (2) of the statutes is amended to read:

AB673,19,11 609.65 (2) If after receiving notice under sub. (1) (b) 2. the health maintenance organization, limited service health organization or preferred provider managed care plan arranges for services to be provided by a provider with whom it has a provider agreement, the health maintenance organization, limited service health organization or preferred provider managed care plan is not required to reimburse a provider under sub. (1) (b) 2. for any services provided after arrangements are made under this subsection.

AB673, s. 48 Section 48. 609.65 (3) of the statutes is amended to read:

AB673,19,22 609.65 (3) A health maintenance organization, limited service health organization or preferred provider managed care plan is only required to make available, or make reimbursement for, an examination, evaluation or treatment under sub. (1) to the extent that the health maintenance organization, limited service health organization or preferred provider managed care plan would have made the medically necessary service available to the enrolled participant enrollee or reimbursed the provider for the service if any referrals required under s. 609.05 (3) had been made and the service had been performed by a participating provider selected by the health maintenance organization, limited service health organization or preferred provider plan.

AB673, s. 49 Section 49. 609.655 (2) of the statutes is amended to read:

AB673,20,6 609.655 (2) If a policy or certificate issued by a health maintenance organization provides coverage of outpatient services provided to a dependent student, the policy or certificate shall provide coverage of outpatient services, to the extent and in the manner required under sub. (3), that are provided to the dependent student while he or she is attending a school located in this state but outside the geographical service area of the health maintenance organization, notwithstanding the limitations regarding selected participating providers, primary providers and referrals under ss. 609.01 (2) and 609.05 (3).

AB673, s. 50 Section 50. 609.655 (5) (a) of the statutes is amended to read:

AB673,20,12 609.655 (5) (a) A policy or certificate issued by a health maintenance organization is required to provide coverage for the services specified in sub. (3) only to the extent that the policy or certificate would have covered the service if it had been provided to the dependent student by a selected participating provider within the geographical service area of the health maintenance organization.

AB673, s. 51 Section 51. 609.655 (5) (b) of the statutes is amended to read:

AB673,20,19 609.655 (5) (b) Paragraph (a) does not permit a health maintenance organization to reimburse a provider for less than the full cost of the services provided or an amount negotiated with the provider, solely because the reimbursement rate for the service would have been less if provided by a selected participating provider within the geographical service area of the health maintenance organization.

AB673, s. 52 Section 52. 609.70 of the statutes is amended to read:

AB673,20,23 609.70 Chiropractic coverage. Health maintenance organizations, limited service health organizations and preferred provider Managed care plans are subject to s. 632.87 (3).

AB673, s. 53 Section 53. 609.75 of the statutes is amended to read:

AB673,21,7 609.75 Adopted children coverage. Health maintenance organizations, limited service health organizations and preferred provider Managed care plans are subject to s. 632.896. Coverage of health care services obtained by adopted children and children placed for adoption may be subject to any requirements that the health maintenance organization, limited service health organization or preferred provider managed care plan imposes under s. 609.05 (2) and (3) on the coverage of health care services obtained by other enrolled participants enrollees.

AB673, s. 54 Section 54. 609.80 of the statutes is amended to read:

AB673,21,13 609.80 Coverage of mammograms. Health maintenance organizations and preferred provider plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the health maintenance organization or preferred provider plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrolled participants enrollees.

AB673, s. 55 Section 55. 609.81 of the statutes is amended to read:

AB673,21,18 609.81 Coverage related to HIV infection. Health maintenance organizations, limited service health organizations and preferred provider Managed care plans are subject to s. 631.93. Health maintenance organizations and preferred provider plans are subject to s. 632.895 (9).

AB673, s. 56 Section 56. 609.91 (1) (intro.) of the statutes is amended to read:

AB673,21,25 609.91 (1) (title) Immunity of enrolled participants enrollees and policyholders. (intro.) Except as provided in sub. (1m), an enrolled participant enrollee or policyholder of a health maintenance organization insurer is not liable for health care costs that are incurred on or after January 1, 1990, and that are covered under a policy or certificate issued by the health maintenance organization insurer, if any of the following applies:

AB673, s. 57 Section 57. 609.91 (1) (b) 2. of the statutes is amended to read:

AB673,22,4 609.91 (1) (b) 2. Is physician services provided under a contract with the health maintenance organization insurer or by a selected participating provider of the health maintenance organization insurer.

AB673, s. 58 Section 58. 609.91 (1) (b) 3. of the statutes is amended to read:

AB673,22,8 609.91 (1) (b) 3. Is services, equipment, supplies or drugs that are ancillary or incidental to services described in subd. 2. and are provided by the contracting provider or selected participating provider.

AB673, s. 59 Section 59. 609.91 (1m) of the statutes is amended to read:

AB673,22,14 609.91 (1m) Immunity of medical assistance recipients. An enrolled participant enrollee, policyholder or insured under a policy issued by an insurer to the department of health and family services under s. 49.45 (2) (b) 2. to provide prepaid health care to medical assistance recipients is not liable for health care costs that are covered under the policy.

AB673, s. 60 Section 60. 609.91 (2) of the statutes is amended to read:

AB673,22,21 609.91 (2) Prohibited recovery attempts. No person may bill, charge, collect a deposit from, seek remuneration or compensation from, file or threaten to file with a credit reporting agency or have any recourse against an enrolled participant enrollee, policyholder or insured, or any person acting on their behalf, for health care costs for which the enrolled participant enrollee, policyholder or insured, or person acting on their behalf, is not liable under sub. (1) or (1m).

AB673, s. 61 Section 61. 609.91 (3) of the statutes is amended to read:

AB673,23,2 609.91 (3) Deductibles, copayments and premiums. Subsections (1) to (2) do not affect the liability of an enrolled participant enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the health maintenance organization insurer or by the insurer described in sub. (1m).

AB673, s. 62 Section 62. 609.91 (4) (intro.) of the statutes is amended to read:

AB673,23,7 609.91 (4) (intro.) Conditions not affecting the immunity. The immunity of an enrolled participant enrollee, policyholder or insured for health care costs, to the extent of the immunity provided under this section and ss. 609.92 to 609.935, is not affected by any of the following:

AB673, s. 63 Section 63. 609.91 (4) (a) of the statutes is amended to read:

AB673,23,14 609.91 (4) (a) An agreement, other than a notice of election or termination of election in accordance with s. 609.92 or 609.925, entered into by the provider, the health maintenance organization insurer, the insurer described in sub. (1m) or any other person, at any time, whether oral or written and whether implied or explicit, including an agreement that purports to hold the enrolled participant enrollee, policyholder or insured liable for health care costs.

AB673, s. 64 Section 64. 609.91 (4) (b) of the statutes is amended to read:

AB673,23,20 609.91 (4) (b) A breach of or default on an agreement by the health maintenance organization insurer, the insurer described in sub. (1m) or any other person to compensate the provider, directly or indirectly, for health care costs, including health care costs for which the enrolled participant enrollee, policyholder or insured is not liable under sub. (1) or (1m).

AB673, s. 65 Section 65. 609.91 (4) (c) of the statutes is amended to read:

AB673,24,5 609.91 (4) (c) The insolvency of the health maintenance organization insurer or any person contracting with the health maintenance organization insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the health maintenance organization insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the health maintenance organization insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrolled participant enrollee or policyholder is not liable under sub. (1).

AB673, s. 66 Section 66. 609.91 (4) (cm) of the statutes is amended to read:

AB673,24,14 609.91 (4) (cm) The insolvency of the insurer described in sub. (1m) or any person contracting with the insurer or provider, or the commencement or the existence of conditions permitting the commencement of insolvency, delinquency or bankruptcy proceedings involving the insurer or other person, including delinquency proceedings, as defined in s. 645.03 (1) (b), under ch. 645, despite whether the insurer or other person has agreed to compensate, directly or indirectly, the provider for health care costs for which the enrolled participant enrollee, policyholder or insured is not liable under sub. (1m).

AB673, s. 67 Section 67. 609.91 (4) (d) of the statutes is amended to read:

AB673,24,20 609.91 (4) (d) The inability of the provider or other person who is owed compensation for health care costs to obtain compensation from the health maintenance organization insurer, the insurer described in sub. (1m) or any other person for health care costs for which the enrolled participant enrollee, policyholder or insured is not liable under sub. (1) or (1m).

AB673, s. 68 Section 68. 609.92 (5) of the statutes is amended to read:

AB673,25,2 609.92 (5) Provider of physician services. A provider who is not under contract with a health maintenance organization insurer and who is not a selected participating provider of a health maintenance organization insurer is not subject to s. 609.91 (1) (b) 2. with respect to health care costs incurred by an enrolled participant enrollee of that health maintenance organization insurer.

AB673, s. 69 Section 69. 609.94 (1) (b) of the statutes is amended to read:

AB673,25,6 609.94 (1) (b) Each selected participating provider of the health maintenance organization insurer, at the time that the provider becomes a selected participating provider.

AB673, s. 70 Section 70. 645.69 (1) of the statutes is amended to read:

AB673,25,12 645.69 (1) A claim against a health maintenance organization insurer or an insurer described in s. 609.91 (1m) for health care costs, as defined in s. 609.01 (1j), for which an enrolled participant enrollee, as defined in s. 609.01 (1d), policyholder or insured of the health maintenance organization insurer or other insurer is not liable under ss. 609.91 to 609.935.

AB673, s. 71 Section 71. 645.69 (2) of the statutes is amended to read: