AB539: Bill Text

LRB-0920/2

RLR&PJK:wlj:md

2009 - 2010 LEGISLATURE

2009 Assembly BILL 539

October 29, 2009 - Introduced by Representatives Vukmir, Kramer, Tauchen, Kerkman, Townsend, Davis, Strachota, Knodl, Murtha, Ripp, Gunderson, Vos, Bies, LeMahieu, Petrowski, Honadel, Nass, Nygren, Van Roy, M. Williams, Suder, J. Ott, Pridemore, Kleefisch, Rhoades, Zipperer, Brooks, Petersen, Lothian, Spanbauer, Huebsch, Newcomer, Montgomery, Nerison, A. Ott, Stone and Kestell, cosponsored by Senators Kanavas, Darling, Hopper, A. Lasee, Schultz and Grothman. Referred to Committee on Health and Healthcare Reform.

AB539,1,6 An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.981 (4t) and 185.983 (1) (intro.); and to create 146.903, 609.71 and 632.798 of the statutes; relating to: disclosure of information by health care providers, insurers, and governmental self-insured plans; requiring acceptance by a health care provider of a payment amount in certain circumstances; and requiring the exercise of rule-making authority.

Analysis by the Legislative Reference Bureau

Under current law, if an applicant for Medical Assistance (MA) is determined to be eligible for MA retroactively (for three months) and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider must submit MA claims for those services and benefits that are covered under MA. Upon receiving MA payment under the claims, the provider must reimburse the MA recipient, or other person who made the prior payment on behalf of the recipient, the amount of the prior payment made for services provided to the recipient during the retroactive eligibility period.

This bill restricts payment that a "health care provider," as defined in the bill, may accept from certain patients who are uninsured or who do not have "public coverage," as defined in the bill. If the patient, within 90 days after receiving a health care service, diagnostic test, or procedure or the first treatment or visit of a course of treatment as part of a health care service, obtains coverage from an insurer or a self-insured health plan under a contract for not less than one year, the health care provider must accept, as payment from the patient for the service, test, or procedure no more than the insurer's or plan's payment amount for that service, test, or procedure, or, if the service or provider is not covered under the coverage the patient obtains, no more than the average rate paid by insurers or self-insured health plans for the service, test, or procedure. However, the patient may be liable to the health care provider for out-of-pocket costs, finance charges, and collection costs incurred that would not have been covered under the patient's coverage. The insurer or self-insured health plan that provides coverage must provide to the patient a dollar estimate of the applicable payment amount for the service, test, or procedure the patient received. A health care provider must provide to a patient who is uninsured or does not have public coverage, at the time the health care service, test, or procedure is provided or after the first treatment or visit of a course of treatment, information about this restriction on payment and information about the restriction on acceptance of patient payment for MA applicants who receive retroactive eligibility.

Under the bill, if a patient is recommended, referred for service, or prescribed a health care service (including any applicable course of treatment), diagnostic test, or procedure for which the charge exceeds $500 or any higher amount that the Department of Health Services (DHS) promulgates by rule (the minimum cost), the health care provider must provide an estimate of the charge to the patient, whether insured or uninsured, or the patient's agent who requests it. The estimate of the charge must be provided at the time of scheduling of the health care service, diagnostic test, procedure, or course of treatment, or within ten business days of the request, whichever is later. The bill specifies numerous requirements for the estimate of charge, except that, in lieu of several of the requirements, a health care provider may provide to the patient or his or her agent an estimate of charge that is a single fixed-price estimate of the total cost of the health care service, diagnostic test, or procedure.

The bill requires DHS, by rule, biennially to adjust the dollar amount that is specified for minimum cost and specifies a procedure, using the consumer price index, by which the adjusted dollar amount must be calculated. DHS may promulgate the amount as an emergency rule without providing a finding of emergency or complying with certain other standards for promulgating emergency rules.

The bill requires a self-insured health plan of the state or a county, city, village, town, or school district, or an insurer that provides health care coverage under a health care plan, including a defined network plan or a sickness care plan operated by a cooperative association, to provide to an insured under the health care plan or an enrollee under the self-insured health plan, any of the following if requested by the insured or enrollee: 1) a description of the coverage, including benefits and cost-sharing requirements, under the health care plan or self-insured health plan; 2) a description of any pre-certification or other requirements that an insured or enrollee must complete before any care is approved by the insurer or self-insured health plan; and 3) a summary of the insured's or enrollee's coverage with respect to a specific medical service or course of treatment. The summary of coverage is based on information relating to an estimate of a charge for a medical service or course of treatment that was provided by a provider or group of providers to the insured or enrollee and must include an estimate of the total out-of-pocket costs that the insured or enrollee may incur, an estimate of the amount that the insurer or self-insured health plan has paid to the provider or providers, any limits on what the insurer or self-insured health plan will pay if the service or course of treatment is received from a nonparticipating or out-of-network provider, and any discounts that the insurer or self-insured health plan is willing to offer the insured or enrollee if the service or course of treatment is received from a different provider.

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:

AB539, s. 1 Section 1. 40.51 (8) of the statutes is amended to read:

AB539,3,5 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (5) (6), 632.895 (5m) and (8) to (15), and 632.896.

AB539, s. 2 Section 2. 40.51 (8m) of the statutes is amended to read:

AB539,3,9 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to (15).

AB539, s. 3 Section 3. 66.0137 (4) of the statutes is amended to read:

AB539,4,2 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4), and (5), and (6), 632.895 (9) to (15), 632.896, and 767.25 (4m) (d) 767.513 (4).

AB539, s. 4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

AB539,4,7 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.87 (4) and, (5), and (6), 632.895 (9) to (15), 632.896, and 767.25 (4m) (d) 767.513 (4).

AB539, s. 5 Section 5. 146.903 of the statutes is created to read:

AB539,4,10 146.903 Disclosures required of health care providers. (1) In this section:

AB539,4,11 (a) "Ambulatory surgical center" has the meaning given in 42 CFR 416.2.

AB539,4,14 (b) "Average paid rate" means the average amount that a health care provider currently accepts as payment in full for a health care service, diagnostic test, or procedure, after any discount applicable to certain patients is applied.

AB539,4,17 (c) "Charged rate" means the average, median, or actual amount that is currently charged by a health care provider to a patient for a health care service, diagnostic test, or procedure.

AB539,4,20 (d) "Clinic" means a place, other than a residence, that is used primarily for the provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and treatment.

AB539,4,24 (e) "Course of treatment" means, as part of a health care service, the management and care, including related therapy and rehabilitation, of a patient over time for the purpose of combating disease or disorder or temporarily or permanently relieving symptoms.

AB539,4,25 (f) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB539,5,2 (g) "Health care provider" has the meaning given in s. 146.81 (1) and includes a clinic and an ambulatory surgical center.

AB539,5,5 (h) "Health care service, diagnostic test, or procedure" includes physical therapy, speech therapy, occupational therapy, chiropractic treatment, or mental therapy, but does not include a prescription drug.

AB539,5,7 (i) "Insured" means covered under a health care plan offered by an insurer or under a self-insured health plan.

AB539,5,15 (j) "Insurer" means an insurer that is authorized to do business in this state, in one or more lines of insurance that includes health insurance, and that provides coverage, excluding public coverage, of health care expenses under health care plans covering individuals or groups in this state. The term includes a health maintenance organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s. 609.01 (4), an insurer operating as a cooperative association organized under ss. 185.981 to 185.985, and a limited service health organization, as defined in s. 609.01 (3).

AB539,5,16 (k) "Medical Assistance" means aid provided under subch. IV of ch. 49.

AB539,5,18 (L) "Medicare" means coverage under Part A or Part B of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395hhh.

AB539,5,20 (m) "Mental therapy" includes services and treatment for mental illness, developmental disability, alcohol and other drug abuse, and drug dependence.

AB539,5,22 (n) "Minimum cost" means $500 or any higher amount that is specified by the department by rule.

AB539,6,2 (p) "Patient's agent" means the parent, guardian, or legal custodian of a minor patient; the spouse of a patient; an agent of a patient under a valid power of attorney for health care; a guardian of the person, as defined in s. 54.01 (12) of a patient; or any individual who is authorized by the patient to act as his or her agent.

AB539,6,3 (q) "Prescription drug" has the meaning given in s. 450.01 (20).

AB539,6,9 (r) "Public coverage" means coverage for health care expenses that is funded in whole or in part under any state-assisted or federally assisted program, including Medical Assistance and Medicare, for which the average reimbursement rate for a health care service, diagnostic test, or procedure is lower than an insurer's or self-insured health plan's average paid rate for the identical service, test, or procedure.

AB539,6,10 (s) "Self-insured health plan" has the meaning given in s. 632.745 (24).

AB539,6,18 (2) (a) If a patient is not insured or does not have public coverage at the time he or she first receives a particular health care service, diagnostic test, or procedure or the first treatment or visit of a course of treatment and, within 90 days after receipt of the service, test, procedure, or treatment, obtains from an insurer or a self-insured health plan coverage that is under a contract for not less than one year, the health care provider shall accept, as payment from the patient for the service, test, procedure, or treatment provided to the patient, whichever of the following is applicable:

AB539,6,22 1. If the health care provider and the service, test, procedure, or treatment are covered under the health care coverage that the patient obtains, an amount that is no more than the insurer's or plan's payment amount for that service, test, or procedure.

AB539,7,2 2. If the health care provider or the service, test, procedure, or treatment is not covered under the health care coverage that the patient obtains, an amount that is no more than the average rate paid by insurers or self-insured health plans for the service, test, procedure, or treatment.

AB539,7,5 (b) A patient under par. (a) may be liable to the health care provider for any out-of-pocket costs, finance charges, and collection costs incurred that would not have been covered under the patient's coverage.

AB539,7,10 (c) The health care provider of a patient who is not insured or who does not have public coverage at the time that a health care service, diagnostic test, or procedure is provided or after the first treatments or visit of a course of treatment shall inform the patient of the requirements under par. (a) and of the provider's reimbursement requirement for a recipient of Medical Assistance under s. 49.49 (3m) (a) 2.

AB539,7,14 (d) The insurer or self-insured health plan that provides coverage specified under par. (a) shall provide to the patient a dollar estimate of the insurer's or plan's applicable payment amount for the health care service, diagnostic test, procedure, or treatment received by the patient, as specified under par. (a).

AB539,7,21 (3) (a) If a patient who is insured or is not insured is recommended to, referred to, or is under the care of a health care provider or group of health care providers for a health care service, including any applicable course of treatment, or diagnostic test or procedure for which the charge exceeds the minimum cost, and if the patient or the patient's agent requests an estimate of the charge, the health care provider or group of health care providers, if applicable, shall provide the patient or the patient's agent with an estimate of the charge.