SB380: Bill Text

SB380,7,20 609.15 (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.

SB380, s. 25 Section 25. 609.15 (1) (b) of the statutes is amended to read:

SB380,7,24 609.15 (1) (b) Provide enrolled participants enrollees with complete and understandable information describing the internal grievance procedure under par. (a).

SB380, s. 26 Section 26. 609.15 (2) (a) of the statutes is amended to read:

SB380,8,2 609.15 (2) (a) The opportunity for an enrolled participant enrollee to submit a written grievance in any form.

SB380, s. 27 Section 27. 609.15 (2) (b) of the statutes is amended to read:

SB380,8,8 609.15 (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.

SB380, s. 28 Section 28. 609.17 of the statutes is amended to read:

SB380,8,15 609.17 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.

SB380, s. 29 Section 29. 609.20 (intro.) of the statutes is amended to read:

SB380,8,19 609.20 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:

SB380, s. 30 Section 30. 609.20 (1) of the statutes is amended to read:

SB380,8,22 609.20 (1) To ensure that enrolled participants enrollees are not forced to travel excessive distances to receive health care services.

SB380, s. 31 Section 31. 609.20 (2) of the statutes is amended to read:

SB380,8,25 609.20 (2) To ensure that the continuity of patient care for enrolled participants enrollees is not disrupted.

SB380, s. 32 Section 32. 609.20 (4) of the statutes is amended to read:

SB380,9,9 609.20 (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.

SB380, s. 33 Section 33. 609.22 of the statutes is created to read:

SB380,9,15 609.22 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:

SB380,9,16 (a) Adequate accessible acute care hospital services for all of its enrollees.

SB380,9,18 (b) An adequate number of accessible primary care physicians for all of its enrollees.

SB380,9,20 (c) Subject to sub. (2), an adequate number of accessible specialist physicians for all of its enrollees within a reasonable distance or travel time.

SB380,9,22 (d) The availability of specialty medical services, including physical therapy, occupational therapy and rehabilitation services.

SB380,9,25 (e) The availability of nonparticipating specialist physicians for enrollees whose medical conditions require services that cannot be provided by participating specialist physicians.

SB380,10,5 (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.

SB380,10,10 (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.

SB380,10,15 (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.

SB380,10,18 (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.

SB380,10,24 (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.

SB380,11,8 (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.

SB380, s. 34 Section 34. 609.24 of the statutes is created to read:

SB380,11,12 609.24 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.

SB380,11,16 (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:

SB380,11,18 (a) A sufficient number of health care professionals who are accepting new enrollees.

SB380,11,21 (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.

SB380,11,24 (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.

SB380,12,4 (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.

SB380,12,9 (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.

SB380,12,11 (5) Second opinions. A managed care plan shall provide an enrollee with coverage for a 2nd opinion from another participating provider.

SB380, s. 35 Section 35. 609.26 of the statutes is created to read:

SB380,12,19 609.26 Drugs and devices. (1) Coverage. (a) A managed care plan shall provide coverage of any drug or device that is approved for use by the federal food and drug administration and that is determined by a treating participating provider to be medically appropriate and necessary for treatment of an enrollee's condition, regardless of whether the drug or device is prescribed by the treating participating provider for the use for which the drug or device is approved by the federal food and drug administration.

SB380,12,21 (b) A treating participating provider shall determine the drug therapy that is appropriate for his or her patient.

SB380,12,23 (c) Prospective review of drug therapy may deny coverage only if any of the following apply:

SB380,12,24 1. A coverage limitation has been reached with respect to the enrollee.

SB380,12,25 2. The enrollee has committed fraud with respect to obtaining the drug.

SB380,13,4 (2) Drug utilization review program. (a) A managed care plan shall establish and operate a drug utilization review program. The primary goal of the program shall be to enhance quality of care for enrollees by ensuring appropriate drug therapy.

SB380,13,5 (b) The program under par. (a) shall include all of the following:

SB380,13,6 1. Retrospective review of prescription drugs furnished to enrollees.

SB380,13,8 2. Ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees.

SB380,13,10 3. An educational outreach program for physicians, pharmacists and enrollees regarding the appropriate use of prescription drugs.

SB380,13,11 (c) The program under par. (a) shall utilize all of the following:

SB380,13,12 1. Clinically relevant criteria and standards for drug therapy.

SB380,13,14 2. Nonproprietary criteria and standards developed and revised through an open, professional consensus process.

SB380,13,15 3. Interventions that focus on improving therapeutic outcomes.

SB380, s. 36 Section 36. 609.28 of the statutes is created to read:

SB380,13,20 609.28 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:

SB380,13,21 (a) Who is authorized to make a determination on the limitation.

SB380,13,23 (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.

SB380,14,3 (2) Denial of treatment. If a 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 provide the enrollee with a denial letter within 20 working days after the request for coverage is submitted. The denial letter shall include all of the following:

SB380,14,4 (a) The name and title of the individual making the decision.

SB380,14,6 (b) A statement setting forth the specific medical and scientific reasons for denying coverage.

SB380,14,8 (c) A description of any alternative treatment, procedures, drugs or devices covered by the plan.

SB380,14,9 (d) A written copy of the plan's grievance and appeal procedure.

SB380, s. 37 Section 37. 609.30 of the statutes is created to read:

SB380,14,14 609.30 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.

SB380,14,18 (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.

SB380,14,24 (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.

SB380, s. 38 Section 38. 609.32 of the statutes is created to read:

SB380,15,4 609.32 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:

SB380,15,5 (a) An ongoing, written internal quality assurance program.

SB380,15,6 (b) Specific written guidelines for quality of care studies and monitoring.

SB380,15,7 (c) Performance and clinical outcomes-based criteria.

SB380,15,9 (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action.

SB380,15,10 (e) A plan for gathering and assessing data.

SB380,15,11 (f) A peer review process.

SB380,15,19 (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.

SB380,15,23 (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:

SB380,15,24 1. Updating the previous review criteria.

SB380,16,2 2. Assessing the provider's performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions.

SB380,16,4 (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.

SB380, s. 39 Section 39. 609.34 of the statutes is created to read:

SB380,16,9 609.34 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.

SB380,16,12 (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.

SB380, s. 40 Section 40. 609.36 of the statutes is created to read:

SB380,16,16 609.36 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:

SB380,16,17 1. The structure of the plan.

SB380,16,18 2. The plan's decision-making process.

SB380,16,19 3. Health care benefits and exclusions.

SB380,16,20 4. Cost-sharing requirements.