SB138: Bill Text

LRB-2078/1

PJK:jld:jd

2015 - 2016 LEGISLATURE

2015 Senate BILL 138

April 28, 2015 - Introduced by Senators Vukmir, Cowles and Nass, cosponsored by Representatives Czaja, Bernier, Edming, Knodl, Krug, T. Larson, Mursau, Rohrkaste and Thiesfeldt. Referred to Committee on Health and Human Services.

SB138,1,3 An Act to amend 185.983 (1) (intro.); and to create 609.72 and 632.799 of the statutes; relating to: information to be provided by insurers about health care plans offered on the American health benefit exchange.

Analysis by the Legislative Reference Bureau

Under the federal Patient Protection and Affordable Care Act (ACA), which was enacted on March 23, 2010, each state must establish an American health benefit exchange (exchange) through which individuals and certain businesses may purchase health insurance. The federal government will establish and operate an exchange in a state that does not establish its own. Health insurance offered through the exchange must meet certain federal requirements, including offering the essential health benefits package that is established by the federal Department of Health and Human Services. Such a health benefit plan is called a qualified health plan (plan) under the ACA.

This bill requires a insurer that offers plans through an exchange that is operating in this state to provide access on the insurer's Internet site to information, in a clear and understandable form, that will enable consumers shopping for health insurance on the exchange to determine all of the following about the insurer's plans offered through the exchange: exclusions from coverage and restrictions on use or quantity of covered services or items; any service or item with a cost-sharing requirement that depends on the cost of the service or item; whether a specific prescription drug is covered and any clinical prerequisites or authorization requirements for coverage of a prescription drug; whether specific types of specialists are included, and whether a specific named specialist is included, in the plan's network; the process for appealing a denial of coverage of a service or item; and how the out-of-pocket costs of medications will or will not be applied towards the deductible under the plan.

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

SB138,1 Section 1. 185.983 (1) (intro.) of the statutes is amended to read:

SB138,2,9 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.799, 632.85, 632.853, 632.855, 632.867, 632.87 (2), (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

SB138,2 Section 2. 609.72 of the statutes is created to read:

SB138,2,12 609.72 Required plan information. Defined network plans are subject to s. 632.799.

SB138,3 Section 3. 632.799 of the statutes is created to read:

SB138,2,15 632.799 Information about plans offered through an American health benefit exchange. (1) Definitions. In this section:

SB138,2,17 (a) "Exchange" means an American health benefit exchange, as described in 42 USC 18031, that is operating in this state.

SB138,2,18 (b) "Qualified health plan" has the meaning given in 42 USC 18021 (a).

SB138,3,4 (2) Information that must be provided. (a) To enable consumers to compare coverage among qualified health plans offered through an exchange, an insurer that offers a qualified health plan through an exchange shall, in addition to any other information that is required under federal law, provide access to information about the qualified health plan, in a clear and understandable form, such that consumers are able to determine all of the following with respect to the qualified health plan:

SB138,3,7 1. Any exclusions from coverage and any restrictions on use or quantity of covered services and items in each category of benefits, including prescription drugs and drugs administered in a physician's office or in a clinic.

SB138,3,10 2. Any service or item with a cost-sharing requirement, including a prescription drug, for which the cost sharing required depends on the cost of the service or item.

SB138,3,14 3. Whether a specific prescription drug is covered by the qualified health plan, whether a specific prescription drug is covered when furnished by a physician or clinic, and any clinical prerequisites or authorization requirements for coverage of a prescription drug.

SB138,3,17 4. Whether specific types of specialists are included in the qualified health plan's network and whether a specific named physician is in the qualified health plan's network.

SB138,3,19 5. The process for an insured to appeal a decision of the qualified health plan denying coverage of a service or item prescribed or ordered by a treating physician.

SB138,3,22 6. How the cost of medications will be included in or excluded from the deductible under the qualified health plan, including a description of out-of-pocket costs for a medication that do not apply towards the deductible.

SB138,3,24 (b) The information required under par. (a) shall be made available on the insurer's Internet site.

SB138,4,2 (c) Nothing in this section requires an insurer to provide information that duplicates information that the insurer already provides.

SB138,4,3 (End)