AB210: Bill Text

AB210,15,17 (3) Employer size election. Notwithstanding s. 636.01 (12), this state reserves the right to elect, as permitted under section 1304 (b) (3) of the Patient Protection and Affordable Care Act, to substitute "51 employees" for "101 employees" and "50 employees" for "100 employees," after the effective date of this subsection .... [LRB inserts date], for any purpose permitted under the Public Health Service Act.

AB210,15,20 636.12 Internal and external appeals. (1) Establishing standards. Notwithstanding any inconsistent provision of chs. 600 to 635 or chs. 644 to 646, the commissioner shall by rule do all of the following:

AB210,15,25 (a) Establish standards for internal appeals that, at a minimum, include consumer protections consistent with section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)), and require an insurer to comply with the standards. The commissioner shall apply the standards established under this paragraph to all of the following:

AB210,16,2 1. Group and individual health insurance coverage subject to section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)).

AB210,16,4 2. Grandfathered health plans that otherwise would be subject to section 2719 (a) of the Public Health Service Act (42 USC 300gg-19 (a)).

AB210,16,6 3. A policy, certificate, or contract that provides only limited-scope dental or vision benefits.

AB210,16,7 4. Coverage specified in s. 632.745 (11) (b) 10.

AB210,16,15 (b) Establish standards for external appeals, including standards for appealing a preexisting condition exclusion denial determination or the rescission of a policy or certificate, and require an insurer to comply with the standards. The commissioner shall adopt standards under this paragraph that comply either with section 2719 (b) (1) of the Public Health Service Act (42 USC 300gg-19 (b) (1)) or with the standards established by the secretary under section 2719 (b) (2) of the Public Health Service Act (42 USC 300gg-19 (b) (2)). The commissioner shall apply the external appeal standards established under this paragraph to all of the following:

AB210,16,17 1. Group and individual health insurance coverage subject to section 2719 (b) of the Public Health Service Act (42 USC 300gg-19 (b)).

AB210,16,18 2. Grandfathered health plans.

AB210,16,19 3. Coverage specified in s. 632.745 (11) (b) 10.

AB210,16,21 4. Coverage specified in s. 632.745 (11) (b) 11., including Medicare supplement or replacement policies, but excluding Medicare advantage plans.

AB210,16,22 (c) Establish standards for independent review organizations.

AB210,16,24 (2) Compliance required. An insurer and an independent review organization shall comply with the rules promulgated under this chapter.

AB210,17,11 636.15 Independent review organizations. (1) Certification. (a) An independent review organization may not perform a review for purposes of the external appeals process established in accordance with standards promulgated under s. 636.12 (1) (b) unless the organization is certified by the commissioner. Unless the commissioner provides otherwise by rule, only an independent review organization that is accredited by a nationally recognized private accreditation organization may be certified under this paragraph. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased and does not have a conflict of interest, as defined by the commissioner by rule. An organization certified under this paragraph must be recertified on a biennial basis.

AB210,17,16 (b) An organization applying for certification or recertification as an independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp) or (Lr). Every organization certified or recertified as an independent review organization shall file a report with the commissioner in accordance with rules promulgated under s. 636.12 (1) (c).

AB210,17,21 (c) An independent review organization that was certified or recertified by the commissioner under s. 632.835, 2009 stats., and whose certification is in effect on the effective date of this paragraph .... [LRB inserts date], shall be considered to have been certified under par. (a), and its certification shall remain in effect until the certification expires or it is revoked or suspended under sub. (5) or s. 227.51 (3).

AB210,18,2 (2) Quality assurance mechanism. An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the independent reviews, the qualifications and independence of the clinical peer reviewers, and the confidentiality of the medical records and review materials.

AB210,18,8 (3) Reasonable fees. An independent review organization shall establish reasonable fees that it will charge for independent reviews and shall submit its fee schedule to the commissioner for a determination of reasonableness and for prior approval. An independent review organization may not change any fees approved by the commissioner more than once per year and shall submit any proposed fee changes to the commissioner for prior approval.

AB210,18,13 (4) Examinations and audits. The commissioner may examine, audit, or accept an audit of, the books and records of an independent review organization as provided for examination of licensees and permittees under s. 601.43 (1), (3), (4), and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

AB210,18,23 (5) Revocation, suspension, refusal to recertify. The commissioner may revoke, suspend, or limit in whole or in part the certification of an independent review organization, or may refuse to recertify an independent review organization, if the commissioner finds that the independent review organization is unqualified or has violated a statute, or a rule promulgated, under chs. 600 to 646 or a valid order of the commissioner under s. 601.41 (4), or if the independent review organization's methods or practices in the conduct of its business endanger, or its financial resources are inadequate to safeguard, the legitimate interests of consumers and the public. The commissioner may summarily suspend an independent review organization's certification under s. 227.51 (3).

AB210,19,3 (6) Decision is binding. Unless otherwise required by the standards under section 2719 (b) of the Public Health Service Act (42 USC 300gg-19 (b)), a decision of an independent review organization is binding on the insured and the insurer.

AB210,19,10 (7) Immunity from liability. (a) An independent review organization that is certified under this section is immune from any civil or criminal liability that may result because of an independent review determination made under the rules promulgated under this chapter. An employee, agent, or contractor of a certified independent review organization is immune from any civil or criminal liability for any act or omission done in good faith within the scope of his or her powers and duties under the rules promulgated under this chapter.

AB210,19,13 (b) An insurer is not liable to any person for damages attributable to the insurer's actions taken in compliance with any decision regarding a determination rendered by a certified independent review organization.

AB210,19,16 (8) Insured's right to commence civil proceeding. Nothing in this section affects an insured's right to commence a civil proceeding relating to a matter that may be appealed under the standards established under s. 636.12 (1).

AB210,19,22 636.18 Rebate and report requirement. Subject to s. 636.35, an insurer offering small employer health insurance or individual health insurance coverage shall comply with section 2718 of the Public Health Service Act (42 USC 300gg-18) and shall file the report required under section 2718 (a) of that act (42 USC 300gg-18 (a)) with the commissioner no later than the date required for filing with the secretary.

AB210,20,2 636.25 Implementing health insurance coverage provisions. Subject to s. 636.35, notwithstanding any inconsistent provision in chs. 600 to 635 or chs. 644 to 646, and unless the commissioner provides otherwise by rule under s. 636.10, all of the following apply:

AB210,20,4 (1) Insurers. An insurer shall comply with all of the following provisions of the Public Health Service Act:

AB210,20,6 (a) Standards relating to benefits for mothers and newborns. Section 2725 (42 USC 300gg-25).

AB210,20,8 (b) Required coverage for reconstructive surgery following mastectomies. Section 2727 (42 USC 300gg-27).

AB210,20,10 (c) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210,20,11 (d) No lifetime limit or annual limits. Section 2711 (42 USC 300gg-11).

AB210,20,12 (e) Prohibition on rescissions. Section 2712 (42 USC 300gg-12).

AB210,20,14 (f) Prohibition on preexisting condition exclusions for under age 19. Section 2704 (42 USC 300gg-04), but only for enrollees who are under 19 years of age.

AB210,20,15 (g) Coverage of preventive health services. Section 2713 (42 USC 300gg-13).

AB210,20,16 (h) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).

AB210,20,17 (i) Provision of additional information. Section 2715A (42 USC 300gg-15a).

AB210,20,19 (j) Patient protections; choice of health care professional. Section 2719A (a) (42 USC 300gg-19a (a)).

AB210,20,23 (k) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)). In addition, an insurer also shall comply with s. 632.85 and an insurer that provides coverage under a defined network plan also shall comply with s. 609.22 (6).

AB210,20,25 (2) Grandfathered health plans. A grandfathered health plan shall comply with all of the following provisions of the Public Health Service Act:

AB210,21,2 (a) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210,21,3 (b) Coverage of preventive health services. Section 2713 (42 USC 300gg-13).

AB210,21,5 (c) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)).

AB210,21,8 (3) Self-insured governmental health plans. A self-insured governmental health plan shall comply with all of the following provisions of the Public Health Service Act:

AB210,21,10 (a) Coverage of dependent students on medically necessary leave of absence. Section 2728 (42 USC 300gg-28).

AB210,21,11 (b) Extension of dependent coverage. Section 2714 (42 USC 300gg-14).

AB210,21,14 (c) Patient protections; coverage of emergency services. Section 2719A (b) (42 USC 300gg-19a (b)). In addition, a self-insured governmental health plan also shall comply with s. 632.85.

AB210,21,16 (4) Additional requirements. With respect to health insurance coverage that is issued or renewed on or after March 23, 2012, all of the following apply:

AB210,21,18 (a) Insurers. An insurer shall comply with all of the following provisions of the Public Health Service Act:

AB210,21,20 1. `Uniform explanation of coverage documents and standardization of definitions.' Section 2715 (42 USC 300gg-15).

AB210,21,21 2. `Ensuring the quality of care.' Section 2717 (42 USC 300gg-17).

AB210,21,24 (b) Grandfathered health plans. A grandfathered health plan shall comply with section 2717 of the Public Health Service Act (42 USC 300gg-17), relating to ensuring the quality of care.

AB210,22,5 (5) Application of section to grandfathered health plans. In addition to subs. (2) and (4) (b), this section applies to a grandfathered health plan, but only with respect to those provisions of the Public Health Service Act referred to in this section that apply to a grandfathered health plan under section 1251 of the Patient Protection and Affordable Care Act.

AB210,22,12 636.35 Applicability if federal law found unconstitutional. If the Patient Protection and Affordable Care Act is found by a final decision of a federal court of competent jurisdiction to be unconstitutional in its entirety and unenforceable in this state, and if all appeals are exhausted or the time for appeal expires, insurers and self-insured governmental health plans are exempt from all of the following provisions on and after the first day of the 3rd month beginning after the date on which all appeals are exhausted or the time for appeal expires:

AB210,22,13 (1) Section 625.13 (3).

AB210,22,14 (2) Section 636.18.

AB210,22,15 (3) Section 636.25, except for s. 636.25 (1) (h) and (3) (b).

AB210,22,17 (4) Chapter 625 with respect to small employer health insurance and group and blanket accident and sickness insurance offered in the individual market.

AB210, s. 44 Section 44 . Initial applicability.

AB210,22,24 (1) Miscellaneous coverage requirements. The treatment of sections 40.51 (8) (by Section 2 ) and (8m) (by Section 4 ), 49.67 (3) (am) 2. b., 66.0137 (4) (by Section 7), 111.91 (2) (n) and (nm), 111.998 (2) (n), 120.13 (2) (g) (by Section 14), 185.983 (1) (intro.) (by Section 16 ), 609.755, 632.76 (2) (ac) 1., 2., 3. (intro.), and 4., 632.885, 632.895 (15) (c) (intro.), and 636.25 (1), (2), (3), and (5) of the statutes first applies to all of the following:

AB210,23,3 (a) Except as provided in paragraphs (b), (c), and (d ), disability insurance policies that are newly issued, and self-insured governmental or school district health plans that are newly established on the effective date of this paragraph.

AB210,23,7 (b) Except as provided in paragraph (d), disability insurance policies, and self-insured governmental or school district health plans, that are grandfathered health plans, as defined in section 636.01 (2) of the statutes, as created by this act, that are renewed, extended, or modified on the effective date of this paragraph.

AB210,23,12 (c) Except as provided in paragraph (d), disability insurance policies, and self-insured governmental or school district health plans, covering employees who are affected by a collective bargaining agreement containing provisions inconsistent with this act that are newly issued or newly established on the earlier of the following:

AB210,23,13 1. The day on which the collective bargaining agreement expires.

AB210,23,15 2. The day on which the collective bargaining agreement is extended, modified, or renewed.

AB210,23,21 (d) Disability insurance policies, and self-insured governmental or school district health plans, that are grandfathered health plans, as defined in section 636.01 (2) of the statutes, as created by this act, that cover employees who are affected by a collective bargaining agreement containing provisions inconsistent with this act, and that are renewed, extended, or modified on the earlier of the following:

AB210,23,22 1. The day on which the collective bargaining agreement expires.

AB210,23,24 2. The day on which the collective bargaining agreement is extended, modified, or renewed.

AB210,24,9 (2) Internal and external appeals. The treatment of sections 40.51 (8) (by Section 1) (with respect to internal and external review procedures), 40.51 (8m) (by Section 3) (with respect to internal and external review procedures), 66.0137 (4) (by Section 6) (with respect to internal and external review procedures), 111.91 (2) (s), 111.998 (2) (s), 120.13 (2) (g) (by Section 13) (with respect to internal and external review procedures), 185.983 (1) (intro.) (by Section 15) (with respect to internal and external review procedures), 600.01 (2) (b), 609.655 (4) (b), 632.83, 632.835, 636.12, and 636.15 of the statutes first applies to appeals filed on the effective date of this subsection.

AB210, s. 45 Section 45. Effective dates. This act takes effect on the day after publication, except as follows:

AB210,24,17 (1) Health insurance coverage provisions. The treatment of sections 40.51 (8) (by Section 2) and (8m) (by Section 4 ), 49.67 (3) (am) 2. b., 66.0137 (4) (by Section 7), 111.91 (2) (n) and (nm), 111.998 (2) (n), 120.13 (2) (g) (by Section 14), 185.983 (1) (intro.) (by Section 16 ), 609.755, 632.76 (2) (ac) 1., 2., 3. (intro.), and 4., 632.885, 632.895 (15) (c) (intro.), 636.25, and 636.35 of the statutes and Section 44 (1) of this act take effect on the first day of the 6th month beginning after publication.

AB210,24,22 (2) Individual and small group health insurance rating. The treatment of sections 601.465 (1m) (d), 625.02 (1), (1h), (1p), (2f), and (2s), 625.13 (1) and (3), and 625.14 of the statutes, the renumbering and amendment of section 625.03 (1m) (e) of the statutes, and the creation of section 625.03 (1m) (e) 2. and 3. of the statutes take effect on September 1, 2011, or on the day after publication, whichever is later.

AB210,24,23 (End)