Amendment ASA1-AB512

LRBs0237/3

PJK:jld:rs

2009 - 2010 LEGISLATURE

ASSEMBLY SUBSTITUTE AMENDMENT 1, TO 2009 ASSEMBLY BILL 512

January 28, 2010 - Offered by Representative Pasch.

AB512-ASA1,2,2 An Act to repeal 632.89 (2) (a) 2., 632.89 (2) (b), 632.89 (2) (c) 2., 632.89 (2) (d) 2., 632.89 (2) (dm) 2., 632.89 (3m), 632.89 (6) and 632.89 (7); to renumber 632.89 (2m), 632.89 (4) and 632.89 (5); to renumber and amend 632.89 (2) (a) 1., 632.89 (2) (c) 1., 632.89 (2) (d) 1., 632.89 (2) (dm) 1. and 632.89 (2) (e); to amend 40.51 (8), 40.51 (8m), 46.10 (8) (d), 46.10 (14) (a), 49.345 (8) (d), 49.345 (14) (a), 66.0137 (4), 120.13 (2) (g), 185.981 (4t), 185.983 (1) (intro.), 301.12 (8) (d), 301.12 (14) (a), 632.89 (title) and 632.89 (2) (title); to repeal and recreate 632.89 (1) (b), 632.89 (1) (em), 632.89 (4) (title) and 632.89 (5) (title); and to create 111.91 (2) (qm), 609.71, 632.89 (1) (at), 632.89 (3), 632.89 (3c), 632.89 (3f), 632.89 (3p), 632.89 (4) (b), 632.89 (5) (a) (title) and 632.89 (5) (c) of the statutes; relating to: health insurance coverage of nervous and mental disorders, alcoholism, and other drug abuse problems; providing an exemption from emergency rule procedures; and granting rule-making authority.

Analysis by the Legislative Reference Bureau

Under current law, a group health insurance policy (called a "disability insurance policy" in the statutes) that provides coverage of any inpatient hospital services must cover those services for the treatment of nervous and mental disorders (mental health) and alcoholism and other drug abuse problems (substance abuse problems) in the minimum amount of the lesser of: 1) the expenses of 30 days of inpatient services; or 2) $7,000 minus the applicable cost sharing under the policy or, if there is no cost sharing under the policy, $6,300 in equivalent benefits measured in services rendered. If a group health insurance policy provides coverage of any outpatient hospital services, it must cover those services for the treatment of mental health and substance abuse problems in the minimum amount of $2,000 minus the applicable cost sharing under the policy or, if there is no cost sharing under the policy, $1,800 in equivalent benefits measured in services rendered. If a group health insurance policy provides coverage of any inpatient or outpatient hospital services, it must cover the cost of transitional treatment arrangements for the treatment of mental health and substance abuse problems in the minimum amount of $3,000 minus the applicable cost sharing under the policy or, if there is no cost sharing under the policy, $2,700 in equivalent benefits measured in services rendered. Transitional treatment arrangements include services, specified by rule by the commissioner of insurance, that are provided in a less restrictive manner than inpatient services but in a more intensive manner than outpatient services. If a group health insurance policy provides coverage for both inpatient and outpatient hospital services, the total coverage for all types of treatment for mental health and substance abuse problems is not required to exceed $7,000, or the equivalent benefits measured in services rendered, in a policy year.

This substitute amendment removes the specified minimum amounts of coverage that a group health insurance policy must provide for the treatment of mental health and substance abuse problems but retains the requirements with respect to providing the coverage. Except for group plans providing limited benefits, the substitute amendment specifically applies the requirements to all types of group health benefit plans, including defined network plans, insurance plans offered by the state, and governmental self-insured health plans of the state and municipalities.

The substitute amendment requires that deductibles, copayments, out-of-pocket limits, limitations regarding referrals to nonphysicians, and other treatment limitations under a group health benefit plan or a governmental self-insured health plan, or under an individual health benefit plan that provides coverage of treatment for mental health or substance abuse problems, may not be more restrictive with respect to that coverage than the most common or frequent type of treatment limitations that apply to substantially all other coverage under the plan. The substitute amendment also requires that expenses incurred for the treatment of mental health and substance abuse problems be included in any overall deductible amount, annual or lifetime limit, or out-of-pocket limit under the plan. The substitute amendment provides two exceptions to these equal coverage requirements. If, as a result of the new requirements, the total cost of coverage to an employer under a group health benefit plan or a governmental self-insured health plan for the treatment of mental health and substance abuse problems increases by more than 2 percent in the first plan year that the requirements apply, or by 1 percent in any plan year thereafter, the employer may elect for the employer's plan to be exempt during the following plan year from the new requirements and subject to the requirements for coverage of the treatment of mental health and substance abuse problems under current law. The cost increase must be determined by a qualified actuary. The second exception is for employers with fewer than ten employees. Any such employer may elect for the employer's plan to be exempt during a plan year from the new requirements and subject to the requirements under current law.

Finally, the substitute amendment requires a group health benefit plan or a governmental self-insured health plan, or an individual health benefit plan that provides coverage of treatment for mental health or substance abuse problems, to make available to an insured or plan participant upon request: 1) the plan's criteria for determining medical necessity for coverage of that treatment; and 2) the reason for any denial of coverage for services for that treatment. Current law requires an insurer that restricts or terminates an insured's coverage that results in the insured's liability for the cost of the treatment to provide on the explanation of benefits form an explanation of the clinical rationale for the restriction or termination of coverage.

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

AB512-ASA1, s. 1 Section 1. 40.51 (8) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,3,6 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, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m) and (8) to (17), and 632.896.

AB512-ASA1, s. 2 Section 2. 40.51 (8m) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,4,4 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, 632.83, 632.835, 632.85, 632.853, 632.855, 632.885, 632.89, and 632.895 (11) to (17).

AB512-ASA1, s. 3 Section 3. 46.10 (8) (d) of the statutes is amended to read:

AB512-ASA1,4,10 46.10 (8) (d) After due regard to the case and to a spouse and minor children who are lawfully dependent on the property for support, compromise or waive any portion of any claim of the state or county for which a person specified under sub. (2) is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or by any other 3rd party.

AB512-ASA1, s. 4 Section 4. 46.10 (14) (a) of the statutes is amended to read:

AB512-ASA1,5,2 46.10 (14) (a) Except as provided in pars. (b) and (c), liability of a person specified in sub. (2) or s. 46.03 (18) for inpatient care and maintenance of persons under 18 years of age at community mental health centers, a county mental health complex under s. 51.08, the centers for the developmentally disabled, the Mendota Mental Health Institute, and the Winnebago Mental Health Institute or care and maintenance of persons under 18 years of age in residential, nonmedical facilities such as group homes, foster homes, treatment foster homes, subsidized guardianship homes, residential care centers for children and youth, and juvenile correctional institutions is determined in accordance with the cost-based fee established under s. 46.03 (18). The department shall bill the liable person up to any amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by other 3rd-party benefits, subject to rules that include formulas governing ability to pay promulgated by the department under s. 46.03 (18). Any liability of the patient not payable by any other person terminates when the patient reaches age 18, unless the liable person has prevented payment by any act or omission.

AB512-ASA1, s. 5 Section 5. 49.345 (8) (d) of the statutes is amended to read:

AB512-ASA1,5,8 49.345 (8) (d) After due regard to the case and to a spouse and minor children who are lawfully dependent on the property for support, compromise or waive any portion of any claim of the state or county for which a person specified under sub. (2) is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or by any other 3rd party.

AB512-ASA1, s. 6 Section 6. 49.345 (14) (a) of the statutes is amended to read:

AB512-ASA1,5,20 49.345 (14) (a) Except as provided in pars. (b) and (c), liability of a person specified in sub. (2) or s. 49.32 (1) for care and maintenance of persons under 18 years of age in residential, nonmedical facilities such as group homes, foster homes, treatment foster homes, subsidized guardianship homes, and residential care centers for children and youth is determined in accordance with the cost-based fee established under s. 49.32 (1). The department shall bill the liable person up to any amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by other 3rd-party benefits, subject to rules that include formulas governing ability to pay established by the department under s. 49.32 (1). Any liability of the person not payable by any other person terminates when the person reaches age 18, unless the liable person has prevented payment by any act or omission.

AB512-ASA1, s. 7 Section 7. 66.0137 (4) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,6,3 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), 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB512-ASA1, s. 8 Section 8. 111.91 (2) (qm) of the statutes is created to read:

AB512-ASA1,6,7 111.91 (2) (qm) The requirements under s. 632.89 relating to coverage of treatment for nervous and mental disorders and alcoholism and other drug problems.

AB512-ASA1, s. 9 Section 9. 120.13 (2) (g) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,6,13 120.13 (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), 632.85, 632.853, 632.855, 632.87 (4), (5), and (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).

AB512-ASA1, s. 10 Section 10. 185.981 (4t) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,6,19 185.981 (4t) A sickness care plan operated by a cooperative association is subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.85, 632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (10) to (17), and 632.897 (10) and chs. 149 and 155.

AB512-ASA1, s. 11 Section 11. 185.983 (1) (intro.) of the statutes, as affected by 2009 Wisconsin Act 28, is amended to read:

AB512-ASA1,7,3 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan 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, 611.67, 619.04, 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, 632.85, 632.853, 632.855, 632.87 (2m), (3), (4), (5), and (6), 632.885, 632.89, 632.895 (5) and (9) to (17), 632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring association shall:

AB512-ASA1, s. 12 Section 12. 301.12 (8) (d) of the statutes is amended to read:

AB512-ASA1,7,9 301.12 (8) (d) After due regard to the case and to a spouse and minor children who are lawfully dependent on the property for support, compromise or waive any portion of any claim of the state or county for which a person specified under sub. (2) is liable, but not any claim payable by an insurer under s. 632.89 (2) or (2m) (4m) or by any other 3rd party.

AB512-ASA1, s. 13 Section 13. 301.12 (14) (a) of the statutes is amended to read:

AB512-ASA1,7,21 301.12 (14) (a) Except as provided in pars. (b) and (c), liability of a person specified in sub. (2) or s. 301.03 (18) for care and maintenance of persons under 17 years of age in residential, nonmedical facilities such as group homes, foster homes, treatment foster homes, residential care centers for children and youth and juvenile correctional institutions is determined in accordance with the cost-based fee established under s. 301.03 (18). The department shall bill the liable person up to any amount of liability not paid by an insurer under s. 632.89 (2) or (2m) (4m) or by other 3rd-party benefits, subject to rules which include formulas governing ability to pay promulgated by the department under s. 301.03 (18). Any liability of the resident not payable by any other person terminates when the resident reaches age 17, unless the liable person has prevented payment by any act or omission.

AB512-ASA1, s. 14 Section 14. 609.71 of the statutes is created to read:

AB512-ASA1,7,24 609.71 Coverage of alcoholism and other diseases. Defined network plans are subject to s. 632.89.

AB512-ASA1, s. 15 Section 15. 632.89 (title) of the statutes is amended to read:

AB512-ASA1,8,2 632.89 (title) Required coverage of Coverage of mental disorders, alcoholism, and other diseases.

AB512-ASA1, s. 16 Section 16. 632.89 (1) (at) of the statutes is created to read:

AB512-ASA1,8,5 632.89 (1) (at) "Group health benefit plan" has the meaning given in s. 632.745 (9).

AB512-ASA1, s. 17 Section 17. 632.89 (1) (b) of the statutes is repealed and recreated to read:

AB512-ASA1,8,7 632.89 (1) (b) "Health benefit plan" has the meaning given in s. 632.745 (11).

AB512-ASA1, s. 18 Section 18. 632.89 (1) (em) of the statutes is repealed and recreated to read:.

AB512-ASA1,8,10 632.89 (1) (em) "Self-insured health plan" has the meaning given in s. 632.745 (24).

AB512-ASA1, s. 19 Section 19. 632.89 (2) (title) of the statutes is amended to read: