Wisconsin 2023-2024 Regular Session

Wisconsin Assembly Bill AB507 Compare Versions

Only one version of the bill is available at this time.

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3	3	2023 - 2024 LEGISLATURE
4	4	2023 ASSEMBLY BILL 507
5	5	October 18, 2023 - Introduced by Representatives VANDERMEER, GUSTAFSON,
6	6	BILLINGS, BRANDTJEN, BROOKS, DONOVAN, GUNDRUM, MACCO, MAGNAFICI,
7	7	MAXEY, RETTINGER, ROZAR, SCHMIDT, SHANKLAND, WICHGERS, WITTKE and
8	8	MELOTIK, cosponsored by Senators TESTIN, BALLWEG, COWLES, L. JOHNSON,
9	9	LARSON and NASS. Referred to Committee on Health, Aging and Long-Term
10	10	Care.
11	11	*AUTHORS SUBJECT TO CHANGE*
12	12	AN ACT to amend 632.85 (title) and 632.85 (3); and to create 632.85 (1) (d) and
13	13	632.851 of the statutes; relating to: prior authorization for coverage of
14	14	physical therapy, occupational therapy, speech therapy, chiropractic services,
15	15	and other services under health plans.
16	16	Analysis by the Legislative Reference Bureau
17	17	Generally, this bill requires and prohibits certain actions related to prior
18	18	authorization of physical therapy, occupational therapy, speech therapy, chiropractic
19	19	services, and other health care services by certain health plans. Under the bill, every
20	20	health plan, when requested to reauthorize coverage, must issue a decision on
21	21	reauthorization of coverage of a service for which prior authorization was previously
22	22	obtained within 48 hours or prior authorization is assumed to be granted. Health
23	23	plans are prohibited under the bill from requiring prior authorization for the first 12
24	24	physical therapy, occupational therapy, speech therapy, or chiropractic visits with no
25	25	duration of care limitation or for any nonpharmacologic management of pain
26	26	provided to individuals with chronic pain for the first 90 days of treatment. The bill
27	27	requires plans to reference the applicable policy and include an explanation to the
28	28	service provider and to the covered individual for any denial of coverage for or
29	29	reduction in covered services. Further, the bill requires plans to compensate
30	30	providers of physical therapy services, occupational therapy services, speech
31	31	therapy services, or chiropractic services as specified under the bill for data entry of
32	32	clinical information that is required by a utilization review organization or
33	33	utilization management organization acting on behalf of a plan. A plan must also
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40	40	impose copayment and coinsurance amounts on covered individuals for provided
41	41	services that are equivalent to copayment and coinsurance amounts imposed for
42	42	primary care services under the plan.
43	43	The bill also requires every utilization review organization and utilization
44	44	management organization that is providing review or management on behalf of a
45	45	health plan to provide to any licensed health care provider, upon request, all medical
46	46	evidence-based policy information that accompanies the algorithms that are used
47	47	to manage coverage and to operate and staff peer review activities with
48	48	Wisconsin-licensed health care providers holding credentials for the type of service
49	49	that is the subject of the review. The bill prohibits utilization review organizations
50	50	and utilization management organizations from using claims data as evidence of
51	51	outcomes for purposes of developing an algorithm to manage coverage or an approval
52	52	policy for coverage. Health plans to which the above requirements and prohibitions
53	53	apply are private health benefit plans and self-insured governmental health plans.
54	54	Additionally, the bill prohibits health care plans and self-insured
55	55	governmental health plans from requiring prior authorization for coverage of any
56	56	covered health care service that is incidental to a covered surgical service and
57	57	determined by the covered person's physician or other health care provider to be
58	58	medically necessary and of any covered urgent health care service as defined in the
59	59	bill. Current law prohibits health care plans and self-insured governmental health
60	60	plans from requiring prior authorization for coverage of emergency medical services.
61	61	This proposal may contain a health insurance mandate requiring a social and
62	62	financial impact report under s. 601.423, stats.
63	63	The people of the state of Wisconsin, represented in senate and assembly, do
64	64	enact as follows:
65	65	SECTION 1. 632.85 (title) of the statutes is amended to read:
66	66	632.85 (title) Coverage without prior authorization for treatment of an
67	67	emergency medical condition; other conditions.
68	68	SECTION 2. 632.85 (1) (d) of the statutes is created to read:
69	69	632.85 (1) (d) “Urgent health care service” means a health care service for
70	70	which the application of the time for making a nonexpedited request for prior
71	71	authorization, in the opinion of a physician or other health care provider with
72	72	knowledge of the covered person's medical condition, could do any of the following:
73	73	1. Seriously jeopardize the life or health of the covered person or the ability of
74	74	that person to regain maximum function.
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87	87	SECTION 2
88	88	ASSEMBLY BILL 507
89	89	2. Subject the covered person to severe pain that cannot be adequately
90	90	managed without the care or treatment that is the subject of the utilization review.
91	91	SECTION 3. 632.85 (3) of the statutes is amended to read:
92	92	632.85 (3) A health care plan or a self-insured health plan that is required to
93	93	provide the coverage under sub. (2) may not require prior authorization for the
94	94	provision or coverage of the emergency medical services specified in sub. (2), any
95	95	covered health care service that is incidental to a covered surgical service and
96	96	determined by the covered person's physician or other health care provider to be
97	97	medically necessary, or any covered health care service that is an urgent health care
98	98	service.
99	99	SECTION 4. 632.851 of the statutes is created to read:
100	100	632.851 Prior authorization; general; physical, occupational, speech
101	101	therapy and chiropractic care. (1) In this section:
102	102	(a) “Episode of care” means treatment for a new or recurring condition for which
103	103	an insured has not been treated within the previous 90 days.
104	104	(b) “Health benefit plan” has the meaning given in s. 632.745 (11).
105	105	(c) “Self-insured health plan” means a self-insured health plan of the state or
106	106	a county, city, village, town, or school district.
107	107	(2) A health benefit plan or self-insured health plan that uses prior
108	108	authorization procedures may not do any of the following:
109	109	(a) Require prior authorization for the first 12 physical therapy, occupational
110	110	therapy, speech therapy, or chiropractic visits with no duration of care limitation. A
111	111	plan may require prior authorization for visits after the initial 12 physical therapy,
112	112	occupational therapy, speech therapy, or chiropractic visits of an episode of care for
113	113	a specific condition.
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140	140	SECTION 4 ASSEMBLY BILL 507
141	141	(b) Require prior authorization for any nonpharmacologic management of pain
142	142	provided to individuals with chronic pain for the first 90 days of treatment.
143	143	(3) A health benefit plan or self-insured health plan that provides coverage of
144	144	physical therapy services, occupational therapy services, speech therapy services, or
145	145	chiropractic services shall do all of the following with respect to such services:
146	146	(a) Reference the applicable policy and include an explanation to the service
147	147	provider and, in plain language, to the covered individual for any denial of coverage
148	148	or reduction in covered services.
149	149	(b) Compensate providers of physical therapy services, occupational therapy
150	150	services, speech therapy services, or chiropractic services at 50 percent of the current
151	151	procedure terminology therapeutic exercise rate for a therapeutic physical therapy
152	152	procedure on one or more areas each lasting 15 minutes for each quarter hour of data
153	153	entry of clinical information that is required by a utilization review organization or
154	154	utilization management organization acting on behalf of a plan. The physical
155	155	therapy service provider, occupational therapy service provider, speech therapy
156	156	service provider, or chiropractic service provider shall invoice the utilization review
157	157	organization or utilization management organization monthly to obtain the
158	158	compensation described under this paragraph or the health benefit plan or
159	159	self-insured health plan shall increase reimbursement to physical therapy service
160	160	providers, occupational therapy service provider, speech therapy service provider, or
161	161	chiropractic service providers commensurate with increased administrative
162	162	expenses.
163	163	(c) Impose copayment and coinsurance amounts on covered individuals for the
164	164	services that are equivalent to copayment and coinsurance amounts imposed on
165	165	covered individuals for primary care services under the plan.
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192	192	JPC:cdc
193	193	SECTION 4
194	194	ASSEMBLY BILL 507
195	195	(4) Every health benefit plan or self-insured health plan when requested to
196	196	reauthorize coverage of a service for which prior authorization was previously
197	197	obtained shall issue the decision on reauthorization within 48 hours of the request.
198	198	If a plan does not issue a decision on reauthorization described under this subsection
199	199	within 48 hours, prior authorization is assumed to be granted for the service.
200	200	(5) Every utilization review organization and utilization management
201	201	organization that is providing review or management on behalf of a health benefit
202	202	plan or self-insured health plan shall do all of the following:
203	203	(a) Provide to any licensed health care provider upon request all medical
204	204	evidence-based policy information that accompanies the algorithms that are used
205	205	to manage coverage. A utilization review organization or utilization management
206	206	organization may not use claims data as evidence of outcomes for purposes of
207	207	developing an algorithm to manage coverage or an approval policy for coverage.
208	208	(b) Operate and staff peer review activities with health care providers that are
209	209	licensed in this state and hold credentials for the type of service that is the subject
210	210	of the review.
211	211	(END)
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