AB673: Bill Text

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AB673, s. 1 Section 1. 40.51 (12) of the statutes is repealed and recreated to read: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AB673, s. 5 Section 5. 609.01 (1) of the statutes is repealed.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.

AB673,10,23 (5) Emergency care. A managed care plan shall cover, and reimburse expenses for, emergency care obtained without prior authorization for the treatment of an emergency medical condition.

AB673,11,4 (6) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs of its enrollees who are members of underserved populations. The managed care plan shall provide culturally appropriate services to the greatest extent possible. If a significant number of enrollees of the plan customarily use languages other than English, the managed care plan shall provide access to personnel who are fluent in those languages to the greatest extent possible.

AB673,11,12 (7) Enrollees held harmless for claims. A limited service health organization or a preferred provider plan shall hold an enrollee harmless against any claim from a participating provider for payment of any portion of the cost of covered health care services. This subsection does not affect the liability of an enrollee, policyholder or insured for any deductibles, copayments or premiums owed under the policy or certificate issued by the limited service health organization insurer or the preferred provider plan insurer. A health maintenance organization is subject to ss. 609.91 to 609.94.

AB673, s. 34 Section 34. 609.24 of the statutes is created to read:

AB673,11,16 609.24 Choice of providers. (1) Adequate choice. A managed care plan shall ensure that each enrollee has adequate choice among participating providers and that the providers are accessible and qualified.

AB673,11,20 (2) Primary providers. Except as provided in sub. (3), a managed care plan shall permit each enrollee to select his or her own primary provider from a list of participating health care professionals. The list shall be updated on an ongoing basis and shall include all of the following:

AB673,11,22 (a) A sufficient number of health care professionals who are accepting new enrollees.

AB673,11,25 (b) A sufficient diversity of health care professionals to adequately meet the needs of an enrollee population with varied characteristics, including age, gender, race and health status.

AB673,12,3 (3) Specialist providers. (a) A managed care plan shall establish a system under which an enrollee with a chronic disease or other special needs may select a participating specialist physician as his or her primary provider.

AB673,12,7 (b) A managed care plan shall allow all enrollees under the plan to have access to specialist physicians on a timely basis when specialty medical care is warranted. An enrollee shall be allowed to choose among participating specialist physicians when a referral is made for specialty care.

AB673,12,12 (4) Point-of-service option. A managed care plan shall offer a point-of-service option, under which an enrollee may obtain covered services from a nonparticipating provider of the enrollee's choice. Under the point-of-service option, the enrollee may be required to pay a reasonable portion of the cost of those services.