AB927: Bill Text

AB927,11,18 609.20 (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, as well as 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.

AB927, s. 35 Section 35. 609.22 of the statutes is created to read:

AB927,11,22 609.22 Access standards. (1) Providers. A managed care plan shall include a sufficient number, and sufficient types, of providers to meet the anticipated needs of its enrollees, with respect to covered benefits.

AB927,11,25 (2) 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.

AB927,12,5 (3) Specialist providers. (a) 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, with respect to covered benefits. An enrollee shall be allowed to choose among participating specialist physicians when a referral is made for specialty care, with respect to covered benefits.

AB927,12,10 (b) If the treatment of a specific condition for which coverage is provided under the plan 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.

AB927,12,15 (4) Primary provider selection. (a) Subject to par. (b), 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 a sufficient number of health care professionals who are accepting new enrollees.

AB927,12,18 (b) A managed care plan shall establish a system under which an enrollee with a chronic disease or other special needs for which coverage is provided under the plan may select a participating specialist physician as his or her primary provider.

AB927,12,20 (5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

AB927,12,23 (6) Emergency care. If a managed care plan provides coverage of emergency services, with respect to covered benefits, the managed care plan shall do all of the following:

AB927,13,3 (a) Cover, and reimburse expenses for, emergency care for which coverage is provided under the plan and that is obtained without prior authorization for the treatment of an emergency medical condition.

AB927,13,8 (b) Cover, and reimburse expenses for, emergency or urgent care for which coverage is provided under the plan and that is provided to an individual who has coverage under the plan as a dependent child and who is a full-time student attending school outside of the geographic service area of the plan, regardless of where the care is provided.

AB927,13,14 (7) 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 for which coverage is provided under the plan. 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, for which coverage is provided under the plan.

AB927,13,20 (8) Access plan for certain enrollees. A managed care plan shall develop an access plan to meet the needs, with respect to covered benefits, of its enrollees who are members of underserved populations. 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.

AB927, s. 36 Section 36. 609.24 of the statutes is created to read:

AB927,14,3 609.24 Continuity of care. (1) Requirement to provide access. (a) Subject to pars. (b) and (c) and except as provided in par. (d), a managed care plan shall provide coverage to an enrollee for the services of a provider, regardless of whether the provider is a participating provider at the time the services are provided, if the managed care plan represented that the provider was, or would be, a participating provider in marketing materials that were provided or available to the enrollee at any of the following times:

AB927,14,5 1. If the plan under which the enrollee has coverage has an open enrollment period, the most recent open enrollment period.

AB927,14,8 2. If the plan under which the enrollee has coverage has no open enrollment period, the time of the enrollee's enrollment or most recent coverage renewal, whichever is later.

AB927,14,10 (b) Except as provided in pars. (c) and (d), a managed care plan shall provide the coverage required under par. (a) for the following period of time:

AB927,14,12 1. For an enrollee of a plan with no open enrollment period, until the end of the current plan year.

AB927,14,15 2. For an enrollee of a plan with an open enrollment period, until the end of the plan year for which it was represented that the provider was, or would be, a participating provider.

AB927,14,21 (c) Except as provided in par. (d), if an enrollee is undergoing a course of treatment with a participating provider who is a specialist physician and whose participation with the plan terminates, the managed care plan is required to provide the coverage under par. (a) only for the remainder of the course of treatment, or for 90 days after the provider's participation with the plan terminates, whichever is shorter.

AB927,14,23 (d) The coverage required under par. (a) need not be provided or may be discontinued if any of the following applies:

AB927,14,25 1. The provider is a health care professional who no longer practices in the managed care plan's geographic service area.

AB927,15,2 2. The insurer issuing the managed care plan terminates or terminated the provider's contract for misconduct on the part of the provider.

AB927,15,5 (e) An insurer issuing a managed care plan shall include in its provider contracts provisions that are reasonable or necessary for compliance with this section.

AB927,15,8 (2) Medical necessity provisions. This section does not preclude the application of any provisions related to medical necessity that are generally applicable under the plan.

AB927, s. 37 Section 37. 609.26 of the statutes is created to read:

AB927,15,12 609.26 Drugs and devices. (1) (a) In this subsection, "off-label use" means a use that is not approved by the federal food and drug administration for a drug or device that is approved by the federal food and drug administration.

AB927,15,15 (b) A managed care plan that provides coverage of prescription drugs or devices may not deny coverage of a prescribed drug or device solely on the basis that the drug or device is prescribed for an off-label use.

AB927,15,18 (2) A managed care plan that provides coverage of only certain specified prescription drugs or devices shall provide coverage of any other prescription drug or device whenever the drug or device is medically necessary.

AB927, s. 38 Section 38. 609.28 of the statutes is created to read:

AB927,15,23 609.28 Experimental treatment. (1) Disclosure of limitations. A managed care plan that limits coverage for experimental treatment shall define the limitation and disclose the limits in any agreement or certificate of coverage. This disclosure shall include the following information:

AB927,15,24 (a) Who is authorized to make a determination on the limitation.

AB927,16,2 (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.

AB927,16,9 (2) Denial of treatment. A managed care plan that receives a request for prior authorization of an experimental procedure that includes sufficient information upon which to make a decision shall, within 5 days after receiving the request, issue a coverage decision. If the managed care plan denies coverage of an experimental treatment, procedure, drug or device for an enrollee who has a terminal condition or illness, the managed care plan shall, as part of its coverage decision, provide the enrollee with a denial letter that includes all of the following:

AB927,16,10 (a) The name and title of the individual making the decision.

AB927,16,12 (b) A statement setting forth the specific medical and scientific reasons for denying coverage.

AB927,16,14 (c) Notice of the enrollee's right to appeal and a description of the appeal procedure.

AB927, s. 39 Section 39. 609.30 of the statutes is created to read:

AB927,16,19 609.30 Provider disclosures. (1) Plan may not contract. A managed care plan may not contract with a participating provider to limit the provider's disclosure of information, to or on behalf of an enrollee, about the enrollee's medical condition or treatment options.

AB927,16,23 (2) Plan may not penalize or terminate. (a) A managed care plan may not penalize a participating provider for discussing with an enrollee financial incentives offered by the plan or other financial arrangements between the plan and the provider.

AB927,17,4 (b) A participating provider may discuss, with or on behalf of an enrollee, all treatment options and any other information that the provider determines to be in the best interest of the enrollee. A managed care plan may not penalize or terminate the contract of a participating provider because the provider makes referrals to other participating providers or discusses medically necessary or appropriate care with or on behalf of an enrollee.

AB927, s. 40 Section 40. 609.32 of the statutes is created to read:

AB927,17,9 609.32 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:

AB927,17,10 (a) An ongoing, written internal quality assurance program.

AB927,17,11 (b) Specific written guidelines for quality of care studies and monitoring.

AB927,17,12 (c) Performance and clinical outcomes-based criteria.

AB927,17,14 (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

AB927,17,15 (e) A plan for gathering and assessing data.

AB927,17,16 (f) A peer review process.

AB927,17,24 (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.

AB927,18,4 (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:

AB927,18,5 1. Updating the previous review criteria.

AB927,18,7 2. Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

AB927,18,9 (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.

AB927, s. 41 Section 41. 609.34 of the statutes is created to read:

AB927,18,14 609.34 Clinical decision-making; 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.

AB927, s. 42 Section 42. 609.36 of the statutes is created to read:

AB927,18,18 609.36 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:

AB927,18,19 1. The structure of the plan.

AB927,18,20 2. The plan's decision-making process.

AB927,18,21 3. Health care benefits and exclusions.

AB927,18,22 4. Cost-sharing requirements.

AB927,18,23 5. Participating providers.

AB927,18,25 (b) Subject to sub. (2), the information and data reported under par. (a) shall be open to public inspection under ss. 19.31 to 19.39.

AB927,19,3 (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.

AB927, s. 43 Section 43. 609.38 of the statutes is created to read:

AB927,19,8 609.38 Oversight. The office shall perform examinations of insurers that issue managed care plans consistent with ss. 601.43 and 601.44. The commissioner shall by rule develop standards for managed care plans for compliance with the requirements under this chapter.

AB927, s. 44 Section 44. 609.65 (1) (intro.) of the statutes is amended to read:

AB927,19,18 609.65 (1) (intro.)  If an enrolled participant of a health maintenance organization, enrollee of a limited service health organization or preferred provider 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:

AB927, s. 45 Section 45. 609.65 (1) (a) of the statutes is amended to read:

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).