AB927: Bill Text

A managed care plan may not penalize or terminate the contract of a participating provider for discussing with an enrollee financial incentives under the plan. A managed care plan may not penalize or terminate the contract of a participating provider for making referrals to other participating providers or for discussing medically necessary or appropriate care with an enrollee.

For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB927, s. 1 Section 1. 40.51 (12) of the statutes is repealed and recreated to read:

AB927,3,4 40.51 (12) Every managed care plan, as defined in s. 609.01 (3c), and every limited service health organization, as defined in s. 609.01 (3), that is offered by the state under sub. (6) shall comply with ch. 609.

AB927, s. 2 Section 2. 40.51 (13) of the statutes is created to read:

AB927,4,3 40.51 (13) Every managed care plan, as defined in s. 609.01 (3c), and every limited service health organization, as defined in s. 609.01 (3), that is offered by the group insurance board under sub. (7) shall comply with ch. 609.

AB927, s. 3 Section 3. 51.20 (7) (am) of the statutes is amended to read:

AB927,4,11 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, 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.

AB927, s. 4 Section 4. 601.42 (1g) (d) of the statutes is amended to read:

AB927,4,18 601.42 (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 is not liable to any person under s. 609.91.

AB927, s. 5 Section 5. Chapter 609 (title) of the statutes is repealed and recreated to read:

AB927,4,21 Chapter 609 managed care plans

AB927, s. 6 Section 6. 609.01 (1) of the statutes is repealed.

AB927, s. 7 Section 7. 609.01 (1c) of the statutes is created to read:

AB927,5,3 609.01 (1c) "Emergency medical condition" means a medical condition that manifests itself by acute 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:

AB927,5,4 (a) Serious jeopardy to the person's health.

AB927,5,5 (b) Serious impairment to the person's bodily functions.

AB927,5,6 (c) Serious dysfunction of any of the person's bodily organs or parts.

AB927, s. 8 Section 8. 609.01 (1d) of the statutes is repealed and recreated to read:

AB927,5,10 609.01 (1d) "Enrollee" means, with respect to a managed care plan or limited service health organization, a person who is entitled to receive health care services under the plan.

AB927, s. 9 Section 9. 609.01 (1g) of the statutes is created to read:

AB927,5,13 609.01 (1g) (a) Except as provided in par. (b), "health benefit plan" means any hospital or medical policy or certificate.

AB927,5,14 (b) "Health benefit plan" does not include any of the following:

AB927,5,16 1. Coverage that is only accident or disability income insurance, or any combination of the 2 types.

AB927,5,17 2. Coverage issued as a supplement to liability insurance.

AB927,5,19 3. Liability insurance, including general liability insurance and automobile liability insurance.

AB927,5,20 4. Worker's compensation or similar insurance.

AB927,5,21 5. Automobile medical payment insurance.

AB927,5,22 6. Credit-only insurance.

AB927,5,23 7. Coverage for on-site medical clinics.

AB927,6,3 8. Other similar insurance coverage, as specified in regulations issued by the federal department of health and human services, under which benefits for medical care are secondary or incidental to other insurance benefits.

AB927,6,9 9. If provided under a separate policy, certificate or contract of insurance, or if otherwise not an integral part of the policy, certificate or contract of insurance: limited-scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination of those benefits; and such other similar, limited benefits as are specified in regulations issued by the federal department of health and human services under section 2791 of P.L. 104-191.

AB927,6,11 10. Hospital indemnity or other fixed indemnity insurance or coverage only for a specified disease or illness, if all of the following apply:

AB927,6,13 a. The benefits are provided under a separate policy, certificate or contract of insurance.

AB927,6,16 b. There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.

AB927,6,19 c. Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.

AB927,6,20 11. Other insurance exempted by rule of the commissioner.

AB927, s. 10 Section 10. 609.01 (1p) of the statutes is created to read:

AB927,6,25 609.01 (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.

AB927, s. 11 Section 11. 609.01 (2) of the statutes is amended to read:

AB927,7,7 609.01 (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.

AB927, s. 12 Section 12. 609.01 (3) of the statutes is amended to read:

AB927,7,14 609.01 (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.

AB927, s. 13 Section 13. 609.01 (3c) of the statutes is created to read:

AB927,7,21 609.01 (3c) "Managed care plan" means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with or employed by the insurer offering the health benefit plan. The term includes a health maintenance organization and a preferred provider plan, but does not include a limited service health organization.

AB927, s. 14 Section 14. 609.01 (3m) of the statutes is created to read:

AB927,8,2 609.01 (3m) "Participating" means, with respect to a physician or other provider, under contract with a managed care plan or limited service health organization to provide health care services, items or supplies to enrollees of the plan.

AB927, s. 15 Section 15. 609.01 (3r) of the statutes is created to read:

AB927,8,4 609.01 (3r) "Physician" has the meaning given in s. 448.01 (5).

AB927, s. 16 Section 16. 609.01 (4) of the statutes is amended to read:

AB927,8,11 609.01 (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.

AB927, s. 17 Section 17. 609.01 (4m) of the statutes is created to read:

AB927,8,14 609.01 (4m) "Primary care physician" means a physician specializing in family medical practice, general internal medicine, obstetrics and gynecology or pediatrics.

AB927, s. 18 Section 18. 609.01 (5) of the statutes is repealed and recreated to read:

AB927,8,17 609.01 (5) "Primary provider" means a participating health care professional who coordinates, supervises and may provide ongoing care to an enrollee.

AB927, s. 19 Section 19. 609.01 (6) of the statutes is repealed and recreated to read:

AB927,8,20 609.01 (6) "Specialist physician" means a physician who is not a primary care physician.

AB927, s. 20 Section 20. 609.01 (7) of the statutes is amended to read:

AB927,8,23 609.01 (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.

AB927, s. 21 Section 21. 609.05 (1) of the statutes is amended to read:

AB927,9,4 609.05 (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.

AB927, s. 22 Section 22. 609.05 (2) of the statutes is amended to read:

AB927,9,8 609.05 (2) A Subject to s. 609.22 (4), a health care plan under sub. (1) may require an enrolled participant enrollee to designate a primary provider and to obtain health care services from the primary provider when reasonably possible.

AB927, s. 23 Section 23. 609.05 (3) of the statutes is amended to read:

AB927,9,14 609.05 (3) Except as provided in ss. 609.65 and 609.655, a health 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.

AB927, s. 24 Section 24. 609.10 (1) (a) of the statutes is amended to read:

AB927,9,21 609.10 (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.

AB927, s. 25 Section 25. 609.15 (1) (intro.) of the statutes is amended to read:

AB927,9,25 609.15 (1) (intro.)  Each health maintenance organization, limited service health organization and preferred provider managed care plan shall do all of the following:

AB927, s. 26 Section 26. 609.15 (1) (a) of the statutes is amended to read:

AB927,10,4 609.15 (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 care plan.

AB927, s. 27 Section 27. 609.15 (1) (b) of the statutes is amended to read:

AB927,10,8 609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).

AB927, s. 28 Section 28. 609.15 (2) (a) of the statutes is amended to read:

AB927,10,11 609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.

AB927, s. 29 Section 29. 609.15 (2) (b) of the statutes is amended to read:

AB927,10,17 609.15 (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.

AB927, s. 30 Section 30. 609.17 of the statutes is amended to read:

AB927,10,24 609.17 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.

AB927, s. 31 Section 31. 609.20 (intro.) of the statutes is amended to read:

AB927,11,3 609.20 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:

AB927, s. 32 Section 32. 609.20 (1) of the statutes is amended to read:

AB927,11,6 609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.

AB927, s. 33 Section 33. 609.20 (2) of the statutes is amended to read:

AB927,11,9 609.20 (2) To ensure that the continuity of patient care for enrolled participants enrollees is not disrupted.

AB927, s. 34 Section 34. 609.20 (4) of the statutes is amended to read:

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.