This bill requires defined network plans, such as health maintenance
organizations, and certain preferred provider plans and self-insured governmental
plans that cover benefits or services provided in either an emergency department of
a hospital or independent freestanding emergency department to cover emergency
medical services without requiring a prior authorization determination and without
regard to whether the health care provider providing the emergency medical services
is a participating provider or facility. If the emergency medical services for which
coverage is required are provided by a nonparticipating provider, the plan must 1)
not impose a prior authorization requirement or other limitation that is more
restrictive than if the service was provided by a participating provider; 2) not impose
cost sharing on an enrollee that is greater than the cost sharing required if the
service was provided by a participating provider; 3) calculate the cost-sharing
amount to be equal to the amount that would have been charged if the service was
provided by a participating provider; 4) provide, within 30 days of the provider's or
facility's bill, an initial payment or denial notice to the provider or facility and then
pay a total amount to the provider or facility that is equal to the amount by which
the provider's or facility's rate exceeds the amount it received in cost sharing from
the enrollee; and 5) count any cost-sharing payment made by the enrollee for the

emergency medical services toward any in-network deductible or out-of-pocket
maximum as if the cost-sharing payment was made for services provided by a
participating provider or facility. The provider or facility may not bill or hold liable
an enrollee of the plan for any amount for the emergency medical service that is more
than the cost-sharing amount that is calculated as described in the bill for the
emergency medical service.
For coverage of an item or service that is provided by a nonparticipating
provider in a participating facility, a plan must 1) not impose a cost-sharing
requirement for the item or service that is greater than the cost-sharing
requirement that would have been imposed if the item or service was provided by a
participating provider; 2) calculate the cost-sharing amount to be equal to the
amount that would have been charged if the service was provided by a participating
provider; 3) provide, within 30 days of the provider's bill, an initial payment or denial
notice to the provider and then pay a total amount to the provider that is equal to the
amount by which the provider's rate exceeds the amount it received in cost sharing
from the enrollee; and 4) count any cost-sharing payment made by the enrollee for
the items or services toward any in-network deductible or out-of-pocket maximum
as if the cost-sharing payment was made for items or services provided by a
participating provider. A nonparticipating provider providing an item or service in
a participating facility may not bill or hold liable an enrollee for more than the
cost-sharing amount unless the provider provides notice and obtains consent as
described in the bill. However, if the nonparticipating provider is providing an
ancillary item or service that is specified in the bill, and the commissioner of
insurance has not specifically allowed balance billing for that item or service by rule,
the nonparticipating provider providing the ancillary item or service in a
participating facility may not bill or hold liable an enrollee for more than the
cost-sharing amount.
Under the bill, a provider or facility that is entitled to a payment for an
emergency medical service or other item or service may initiate open negotiations
with the defined network plan, preferred provider plan, or self-insured
governmental health plan to determine the amount of payment. If the open
negotiation period terminates without determination of the payment amount, the
provider, facility, or plan may initiate the independent dispute resolution process as
specified by the commissioner of insurance. If an enrollee of a plan is a continuing
care patient, as defined in the bill, and is obtaining services from a participating
provider or facility, and the contract is terminated because of a change in the terms
of the participation of the provider or facility in the plan or the contract is terminated,
resulting in a loss of benefits under the plan, the plan must notify the enrollee of the
enrollee's right to elect to continue transitional care, provide the enrollee an
opportunity to notify the plan of the need for transitional care, and allow the enrollee
to continue to have the benefits provided under the plan under the same terms and
conditions as would have applied without the termination until either 90 days after
the termination notice date or the date on which the enrollee is no longer a continuing
care patient, whichever is earlier. If a continuing care patient would qualify for
continued care for a longer period under current law than specified in the bill, the

bill specifies that the continuing care patient may continue to receive coverage for
the longer period provided under current law.
This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB743,1 1Section 1 . 609.045 of the statutes is created to read:
SB743,3,3 2609.045 Balance billing; emergency medical services. (1) Definitions.
3In this section:
SB743,3,74 (a) “Emergency medical services” means emergency medical services for which
5coverage is required under s. 632.85 (2) and includes emergency medical services
6described under s. 632.85 (2) as if section 1867 of the federal Social Security Act
7applied to an independent freestanding emergency department.
SB743,3,118 (b) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
9preferred provider plan, as defined in s. 609.01 (4), that has a network of
10participating providers and imposes on enrollees different requirements for using
11providers that are not participating providers.
SB743,3,1512 (c) “Self-insured governmental plan” means a self-insured health plan of the
13state or a county, city, village, town, or school district that has a network of
14participating providers and imposes on enrollees in the self-insured health plan
15different requirements for using providers that are not participating providers.
SB743,3,20 16(2) Emergency medical services. A defined network plan, preferred provider
17plan, or self-insured governmental plan that covers any benefits or services provided
18in an emergency department of a hospital or emergency medical services provided
19in an independent freestanding emergency department shall cover emergency
20medical services in accordance with all of the following:
SB743,4,1
1(a) The plan may not require a prior authorization determination.
SB743,4,42 (b) The plan may not deny coverage on the basis of whether or not the health
3care provider providing the services is a participating provider or participating
4emergency facility.
SB743,4,75 (c) If the emergency medical services are provided to an enrollee by a provider
6or in a facility that is not a participating provider or participating facility, the plan
7complies with all of the following:
SB743,4,118 1. The emergency medical services are covered without imposing on an enrollee
9a requirement for prior authorization or any coverage limitation that is more
10restrictive than requirements or limitations that apply to emergency medical
11services provided by participating providers or in participating facilities.
SB743,4,1512 2. Any cost-sharing requirement imposed on an enrollee for the emergency
13medical services is no greater than the requirements that would apply if the
14emergency medical services were provided by a participating provider or in a
15participating facility.
SB743,4,2016 3. Any cost-sharing amount imposed on an enrollee for the emergency medical
17services is calculated as if the total amount that would have been charged for the
18emergency medical services if provided by a participating provider or in a
19participating facility is equal to the amount paid to the provider or facility that is not
20a participating provider or participating facility as determined by the commissioner.
SB743,4,2121 4. The plan does all of the following:
SB743,4,2422 a. No later than 30 days after the provider or facility transmits to the plan the
23bill for emergency medical services, sends to the provider or facility an initial
24payment or a notice of denial of payment.
SB743,5,4
1b. Pays to the provider or facility a total amount that, incorporating any initial
2payment under subd. 4. a., is equal to the amount by which the rate for a provider
3or facility that is not a participating provider or facility exceeds the cost-sharing
4amount.
SB743,5,95 5. The plan counts any cost-sharing payment made by the enrollee for the
6emergency medical services toward any in-network deductible or out-of-pocket
7maximum applied by the plan in the same manner as if the cost-sharing payment
8was made for emergency medical services provided by a participating provider or in
9a participating facility.
SB743,5,20 10(3) Provider billing limitation for emergency medical services; ambulance
11services.
A provider of emergency medical services or a facility in which emergency
12medical services are provided that is entitled to payment under sub. (2) may not bill
13or hold liable an enrollee for any amount for the emergency medical service that is
14more than the cost-sharing amount determined under sub. (2) (c) 3. for the
15emergency service. A provider of ambulance services that is not a participating
16provider under an enrollee's defined network plan, preferred provider plan, or
17self-insured governmental plan may not bill or hold liable an enrollee for any
18amount of the ambulance service that is more than the cost-sharing amount that the
19enrollee would be charged if the provider of ambulance services was a participating
20provider under the enrollee's plan.
SB743,6,2 21(4) Nonparticipating provider in participating facility. For items or services
22other than emergency medical services that are provided to an enrollee of a defined
23network plan, preferred provider plan, or self-insured governmental plan by a
24provider that is not a participating provider but is providing services at a

1participating facility, the plan shall provide coverage for the item or service in
2accordance with all of the following:
SB743,6,53 (a) The plan may not impose on an enrollee a cost-sharing requirement for the
4item or service that is greater than the cost-sharing requirement that would have
5been imposed if the item or service was provided by a participating provider.
SB743,6,96 (b) Any cost-sharing amount imposed on an enrollee for the item or service is
7calculated as if the total amount that would have been charged for the item or service
8if provided by a participating provider is equal to the amount paid to the provider
9that is not a participating provider as determined by the commissioner.
SB743,6,1110 (c) No later than 30 days after the provider transmits the bill for services, the
11plan shall send to the provider an initial payment or a notice of denial of payment.
SB743,6,1512 (d) The plan shall make a total payment directly to the provider that provided
13the item or service to the enrollee that, added to any initial payment described under
14par. (c), is equal to the amount by which the out-of-network rate for the item or
15service exceeds the cost-sharing amount.
SB743,6,1916 (e) The plan counts any cost-sharing payment made by the enrollee for the item
17or service toward any in-network deductible or out-of-pocket maximum applied by
18the plan in the same manner as if the cost-sharing payment was made for the item
19or service when provided by a participating provider.
SB743,6,25 20(5) Charging for services by nonparticipating provider; notice and consent.
21(a) Except as provided in par. (c), a provider of an item or service that is entitled to
22payment under sub. (4) may not bill or hold liable an enrollee for any amount for the
23item or service that is more than the cost-sharing amount calculated under sub. (4)
24(b) for the item or service unless the nonparticipating provider provides notice and
25obtains consent in accordance with all of the following:
SB743,7,3
11. The notice states that the provider is not a participating provider in the
2enrollee's defined network plan, preferred provider plan, or self-insured
3governmental plan.
SB743,7,74 2. The notice provides a good faith estimate of the amount that the
5nonparticipating provider may charge the enrollee for the item or service involved,
6including notification that the estimate does not constitute a contract with respect
7to the charges estimated for the item or service.
SB743,7,108 3. The notice includes a list of the participating providers at the participating
9facility that would be able to provide the item or service and notification that the
10enrollee may be referred to one of those participating providers.
SB743,7,1311 4. The notice includes information about whether or not prior authorization or
12other care management limitations may be required before receiving an item or
13service at the participating facility.
SB743,7,1514 5. The notice clearly states that consent is optional and that the patient may
15elect to seek care from an in-network provider.
SB743,7,1616 6. The notice is worded in plain language.
SB743,7,1817 7. The notice is available in languages other than English. The commissioner
18shall identify languages for which the notice should be available.
SB743,7,2319 8. The enrollee provides consent to the nonparticipating provider to be treated
20by the nonparticipating provider, and the consent acknowledges that the enrollee
21has been informed that the charge paid by the enrollee may not meet a limitation that
22the enrollee's defined network plan, preferred provider plan, or self-insured
23governmental plan places on cost sharing, such as an in-network deductible.
SB743,7,2524 9. A signed copy of the consent described under subd. 8. is provided to the
25enrollee.
SB743,8,2
1(b) To be considered adequate, the notice and consent under par. (a) shall meet
2one of the following requirements, as applicable:
SB743,8,63 1. If the enrollee makes an appointment for the item or service at least 72 hours
4before the day on which the item or service is to be provided, any notice under par.
5(a) shall be provided to the enrollee at least 72 hours before the day of the
6appointment at which the item or service is to be provided.
SB743,8,97 2. If the enrollee makes an appointment for the item or service less than 72
8hours before the day on which the item or service is to be provided, any notice under
9par. (a) shall be provided to the enrollee on the day that the appointment is made.
SB743,8,1410 (c) A provider of an item or service that is entitled to payment under sub. (4)
11may not bill or hold liable an enrollee for any amount for an ancillary item or service
12that is more than the cost-sharing amount determined under sub. (4) (b) for the item
13or service, unless the commissioner specifies by rule that the provider may balance
14bill for the ancillary item or service, if the item or service is any of the following:
SB743,8,1515 1. Related to an emergency medical service.
SB743,8,1616 2. Anesthesiology.
SB743,8,1717 3. Pathology.
SB743,8,1818 4. Radiology.
SB743,8,1919 5. Neonatology.
SB743,8,2120 6. An item or service provided by an assistant surgeon, hospitalist, or
21intensivist.
SB743,8,2222 7. A diagnostic service, including a radiology or laboratory service.
SB743,8,2423 8. An item or service provided by a specialty practitioner that the commissioner
24specifies by rule.
SB743,9,3
19. An item or service provided by a nonparticipating provider when there is no
2participating provider that can furnish the item or service at the participating
3facility.
SB743,9,64 (d) Any notice and consent provided under par. (a) may not extend to items or
5services furnished as a result of unforeseen, urgent medical needs that arise at the
6time the item or service is provided.
SB743,9,87 (e) Any consent provided under par. (a) shall be retained by the provider for no
8less than 7 years.
SB743,9,18 9(6) Notice by provider or facility. Beginning no later than January 1, 2024,
10a health care provider or health care facility shall make available, including posting
11on a website, to enrollees in defined network plans, preferred provider plans, and
12self-insured governmental plans notice of the requirements on a provider or facility
13under subs. (3) and (5), of any other applicable state law requirements on the
14provider or facility with respect to charging an enrollee for an item or service if the
15provider or facility does not have a contractual relationship with the plan, and of
16information on contacting appropriate state or federal agencies in the event the
17enrollee believes the provider or facility violates any of the requirements under this
18section or other applicable law.
SB743,9,25 19(7) Negotiation; dispute resolution. A provider or facility that is entitled to
20receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (4) (c) may
21initiate, within 30 days of receiving the initial payment or notice of denial, open
22negotiations with the defined network plan, preferred provider plan, or self-insured
23governmental plan to determine a payment amount for an emergency medical
24service or other item or service for a period that terminates 30 days after initiating
25open negotiations. If the open negotiation period under this subsection terminates

1without determination of a payment amount, the provider, facility, defined network
2plan, preferred provider plan, or self-insured governmental plan may initiate,
3within the 4 days beginning on the day after the open negotiation period ends, the
4independent dispute resolution process as specified by the commissioner. If the
5independent dispute resolution decision maker determines the payment amount,
6the party to the independent dispute resolution process whose amount was not
7selected shall pay the fees for the independent dispute resolution. If the parties to
8the independent dispute resolution reach a settlement on the payment amount, the
9parties to the independent dispute resolution shall equally divide the payment for
10the fees for the independent dispute resolution.
SB743,10,11 11(8) Continuity of care. (a) In this subsection:
SB743,10,1212 1. “Continuing care patient” means an individual who is any of the following:
SB743,10,1413 a. Undergoing a course of treatment for a serious and complex condition from
14a provider or facility.
SB743,10,1615 b. Undergoing a course of institutional or inpatient care from a provider or
16facility.
SB743,10,1817 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
18care, from a provider or facility.
SB743,10,2019 d. Pregnant and undergoing a course of treatment for the pregnancy from a
20provider or facility.
SB743,10,2221 e. Terminally ill and receiving treatment for the illness from a provider or
22facility.
SB743,10,2323 2. “Serious and complex condition” means any of the following:
SB743,11,3
1a. In the case of an acute illness, a condition that is serious enough to require
2specialized medical treatment to avoid the reasonable possibility of death or
3permanent harm.
SB743,11,64 b. In the case of a chronic illness or condition, a condition that is
5life-threatening, degenerative, potentially disabling, or congenital and requires
6specialized medical care over a prolonged period.
SB743,11,137 (b) If an enrollee is a continuing care patient and is obtaining items or services
8from a participating provider or participating facility and the contract between the
9defined network plan, preferred provider plan, or self-insured governmental plan
10and the participating provider or participating facility is terminated or the coverage
11of benefits that include the items or services provided by the participating provider
12or participating facility are terminated by the plan, the plan shall do all of the
13following:
SB743,11,1614 1. Notify each enrollee of the termination of the contract or benefits and of the
15right for the enrollee to elect to continue transitional care from the provider or facility
16under this subsection.
SB743,11,1817 2. Provide the enrollee an opportunity to notify the plan of the need for
18transitional care.
SB743,11,2519 3. Allow the enrollee to elect to continue to have the benefits provided under
20the plan under the same terms and conditions as would have applied to the item or
21service if the termination had not occurred for the course of treatment related to the
22enrollee's status as a continuing care patient beginning on the date on which the
23notice under subd. 1. is provided and ending 90 days after the date on which the
24notice under subd. 1. is provided or the date on which the enrollee is no longer a
25continuing care patient, whichever is earlier.
SB743,12,3
1(c) The provisions of s. 609.24 apply to a continuing care patient to the extent
2that s. 609.24 does not conflict with this subsection so as to limit the enrollee's rights
3under this subsection.
SB743,12,8 4(9) Rule making. The commissioner may promulgate any rules necessary to
5implement this section, including specifying the independent dispute resolution
6process under sub. (7). The commissioner may promulgate rules to modify the list
7of those items and services for which a provider may not balance bill under sub. (5)
8(c).
SB743,12,99 (End)
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