AB927: Bill Text

AB927,19,25 609.65 (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.

AB927, s. 46 Section 46. 609.65 (1) (b) (intro.) of the statutes is amended to read:

AB927,20,9 609.65 (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:

AB927, s. 47 Section 47. 609.65 (1) (b) 1. of the statutes is amended to read:

AB927,20,15 609.65 (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.

AB927, s. 48 Section 48. 609.65 (1) (b) 2. of the statutes is amended to read:

AB927,20,21 609.65 (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.

AB927, s. 49 Section 49. 609.65 (2) of the statutes is amended to read:

AB927,21,4 609.65 (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.

AB927, s. 50 Section 50. 609.65 (3) of the statutes is amended to read:

AB927,21,15 609.65 (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.

AB927, s. 51 Section 51. 609.655 (1) (a) 1. of the statutes is amended to read:

AB927,21,19 609.655 (1) (a) 1. Is covered as a dependent child under the terms of a policy or certificate issued by a health maintenance organization managed care plan insurer.

AB927, s. 52 Section 52. 609.655 (1) (a) 2. of the statutes is amended to read:

AB927,21,23 609.655 (1) (a) 2. Is enrolled in a school located in this state but outside the geographical service area of the health maintenance organization managed care plan.

AB927, s. 53 Section 53. 609.655 (2) of the statutes is amended to read:

AB927,22,9 609.655 (2) If a policy or certificate issued by a health maintenance organization managed care plan insurer 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 managed care plan, notwithstanding the limitations regarding selected participating providers, primary providers and referrals under ss. 609.01 (2) and 609.05 (3).

AB927, s. 54 Section 54. 609.655 (3) (intro.) of the statutes is amended to read:

AB927,22,13 609.655 (3) (intro.)  Except as provided in sub. (5), a health maintenance organization managed care plan shall provide coverage for all of the following services:

AB927, s. 55 Section 55. 609.655 (3) (a) of the statutes is amended to read:

AB927,22,20 609.655 (3) (a) A clinical assessment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems, conducted by a provider described in s. 632.89 (1) (e) 2. or 3. who is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and who may be designated by the health maintenance organization managed care plan.

AB927, s. 56 Section 56. 609.655 (3) (b) (intro.) of the statutes is amended to read:

AB927,23,2 609.655 (3) (b) (intro.) If outpatient services are recommended in the clinical assessment conducted under par. (a), the recommended outpatient services consisting of not more than 5 visits to an outpatient treatment facility or other provider that is located in this state and in reasonably close proximity to the school in which the dependent student is enrolled and that may be designated by the health maintenance organization managed care plan, except as follows:

AB927, s. 57 Section 57. 609.655 (3) (b) 1. of the statutes is amended to read:

AB927,23,7 609.655 (3) (b) 1. Coverage is not required under this paragraph if the medical director of the health maintenance organization managed care plan determines that the nature of the treatment recommended in the clinical assessment will prohibit the dependent student from attending school on a regular basis.

AB927, s. 58 Section 58. 609.655 (4) (a) of the statutes is amended to read:

AB927,23,18 609.655 (4) (a) Upon completion of the 5 visits for outpatient services covered under sub. (3) (b), the medical director of the health maintenance organization managed care plan and the clinician treating the dependent student shall review the dependent student's condition and determine whether it is appropriate to continue treatment of the dependent student's nervous or mental disorders or alcoholism or other drug abuse problems in reasonably close proximity to the school in which the student is enrolled. The review is not required if the dependent student is no longer enrolled in the school or if the coverage limits under the policy or certificate for treatment of nervous or mental disorders or alcoholism or other drug abuse problems have been exhausted.

AB927, s. 59 Section 59. 609.655 (4) (b) of the statutes is amended to read:

AB927,24,3 609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the health maintenance organization managed care plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the health maintenance organization's managed care plan's internal grievance procedure established under s. 609.15.

AB927, s. 60 Section 60. 609.655 (5) (a) of the statutes is amended to read:

AB927,24,10 609.655 (5) (a) A policy or certificate issued by a health maintenance organization managed care plan insurer 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 managed care plan.

AB927, s. 61 Section 61. 609.655 (5) (b) of the statutes is amended to read:

AB927,24,17 609.655 (5) (b) Paragraph (a) does not permit a health maintenance organization managed care plan 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 managed care plan.

AB927, s. 62 Section 62. 609.70 of the statutes is amended to read:

AB927,24,21 609.70 Chiropractic coverage. Health maintenance organizations, limited Limited service health organizations and preferred provider managed care plans are subject to s. 632.87 (3).

AB927, s. 63 Section 63. 609.75 of the statutes is amended to read:

AB927,25,4 609.75 Adopted children coverage. Health maintenance organizations, limited 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.

AB927, s. 64 Section 64. 609.77 of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

AB927,25,9 609.77 Coverage of breast reconstruction. Health maintenance organizations, limited Limited service health organizations and preferred provider managed care plans are subject to s. 632.895 (13).

AB927, s. 65 Section 65. 609.78 of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

AB927,25,15 609.78 Coverage of treatment for the correction of temporomandibular disorders. Health maintenance organizations, limited Limited service health organizations and preferred provider managed care plans are subject to s. 632.895 (11).

AB927, s. 66 Section 66. 609.79 of the statutes, as created by 1997 Wisconsin Act 27, is amended to read:

AB927,25,21 609.79 Coverage of hospital and ambulatory surgery center charges and anesthetics for dental care. Health maintenance organizations, limited Limited service health organizations and preferred provider managed care plans are subject to s. 632.895 (12).

AB927, s. 67 Section 67. 609.80 of the statutes is amended to read:

AB927,26,3 609.80 Coverage of mammograms. Health maintenance organizations and preferred provider Managed care 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 managed care plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrolled participants enrollees.

AB927, s. 68 Section 68. 609.81 of the statutes is amended to read:

AB927,26,8 609.81 Coverage related to HIV infection. Health maintenance organizations, limited Limited service health organizations and preferred provider managed care plans are subject to s. 631.93. Health maintenance organizations and preferred provider Managed care plans are subject to s. 632.895 (9).

AB927, s. 69 Section 69. 609.91 (1) (intro.) of the statutes is amended to read:

AB927,26,15 609.91 (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:

AB927, s. 70 Section 70. 609.91 (1) (b) 2. of the statutes is amended to read:

AB927,26,19 609.91 (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.

AB927, s. 71 Section 71. 609.91 (1) (b) 3. of the statutes is amended to read:

AB927,26,23 609.91 (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.

AB927, s. 72 Section 72. 609.91 (1m) of the statutes is amended to read:

AB927,27,5 609.91 (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.

AB927, s. 73 Section 73. 609.91 (2) of the statutes is amended to read:

AB927,27,12 609.91 (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).

AB927, s. 74 Section 74. 609.91 (3) of the statutes is amended to read:

AB927,27,18 609.91 (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).

AB927, s. 75 Section 75. 609.91 (4) (intro.) of the statutes is amended to read:

AB927,27,23 609.91 (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:

AB927, s. 76 Section 76. 609.91 (4) (a) of the statutes is amended to read:

AB927,28,6 609.91 (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.

AB927, s. 77 Section 77. 609.91 (4) (b) of the statutes is amended to read:

AB927,28,12 609.91 (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).

AB927, s. 78 Section 78. 609.91 (4) (c) of the statutes is amended to read:

AB927,28,22 609.91 (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).

AB927, s. 79 Section 79. 609.91 (4) (cm) of the statutes is amended to read:

AB927,29,6 609.91 (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).

AB927, s. 80 Section 80. 609.91 (4) (d) of the statutes is amended to read:

AB927,29,12 609.91 (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).

AB927, s. 81 Section 81. 609.92 (5) of the statutes is amended to read:

AB927,29,18 609.92 (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.

AB927, s. 82 Section 82. 609.94 (1) (b) of the statutes is amended to read:

AB927,29,22 609.94 (1) (b) Each selected participating provider of the health maintenance organization insurer, at the time that the provider becomes a selected participating provider.

AB927, s. 83 Section 83. 645.69 (1) of the statutes is amended to read:

AB927,30,3 645.69 (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.

AB927, s. 84 Section 84. 645.69 (2) of the statutes is amended to read:

AB927,30,7 645.69 (2) A claim for health care costs, as defined in s. 609.01 (1j), for which an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a health maintenance organization is not liable for any reason.

AB927, s. 85 Section 85. 646.31 (1) (d) 8. of the statutes is amended to read:

AB927,30,11 646.31 (1) (d) 8. Made for health care costs, as defined in s. 609.01 (1j), for which an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a health maintenance organization insurer is not liable under ss. 609.91 to 609.935.

AB927, s. 86 Section 86. 646.31 (1) (d) 9. of the statutes is amended to read:

AB927,30,15 646.31 (1) (d) 9. Made for health care costs, as defined in s. 609.01 (1j), for which an enrolled participant enrollee, as defined in s. 609.01 (1d), or policyholder of a health maintenance organization is not liable for any reason.

AB927, s. 87 Section 87 . Initial applicability.

AB927,30,20 (1) If a contract that is in effect on January 1, 1999, that is affected by this act and that was not issued or renewed after the effective date of this subsection contains terms or provisions that are inconsistent with the requirements under this act, this act first applies to that contract upon renewal.

AB927,30,25 (2) If a contract that is in effect on January 1, 1999, that is affected by this act and that is affected by a collective bargaining agreement that was not extended, modified or renewed after the effective date of this subsection contains terms or provisions that are inconsistent with this act, this act first applies to that contract on the earlier of the following:

AB927,31,1 (a) The day on which the collective bargaining agreement expires.

AB927,31,3 (b) The day on which the collective bargaining agreement is extended, modified or renewed.

AB927, s. 88 Section 88. Effective dates. This act takes effect on January 1, 1999, or on the day after publication, whichever is later, except as follows: