Wisconsin 2023-2024 Regular Session

Wisconsin Assembly Bill AB784 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 784
5	5	December 8, 2023 - Introduced by Representatives J. ANDERSON, ANDRACA, BALDEH,
6	6	BARE, CLANCY, CONLEY, DRAKE, EMERSON, JACOBSON, JOERS, MADISON, MOORE
7	7	OMOKUNDE, ORTIZ-VELEZ, PALMERI, SHANKLAND, SHELTON, SNODGRASS,
8	8	SORTWELL, STUBBS and SUBECK, cosponsored by Senators SMITH, LARSON, L.
9	9	JOHNSON and WIRCH. Referred to Committee on Insurance.
10	10	*AUTHORS SUBJECT TO CHANGE*
11	11	AN ACT to create 609.045 of the statutes; relating to: insurance coverage and
12	12	balance billing for certain health care services and granting rule-making
13	13	authority.
14	14	Analysis by the Legislative Reference Bureau
15	15	This bill requires defined network plans, such as health maintenance
16	16	organizations, and certain preferred provider plans and self-insured governmental
17	17	plans that cover benefits or services provided in either an emergency department of
18	18	a hospital or independent freestanding emergency department to cover emergency
19	19	medical services without requiring a prior authorization determination and without
20	20	regard to whether the health care provider providing the emergency medical services
21	21	is a participating provider or facility. If the emergency medical services for which
22	22	coverage is required are provided by a nonparticipating provider, the plan must 1)
23	23	not impose a prior authorization requirement or other limitation that is more
24	24	restrictive than if the service was provided by a participating provider; 2) not impose
25	25	cost sharing on an enrollee that is greater than the cost sharing required if the
26	26	service was provided by a participating provider; 3) calculate the cost-sharing
27	27	amount to be equal to the amount that would have been charged if the service was
28	28	provided by a participating provider; 4) provide, within 30 days of the provider's or
29	29	facility's bill, an initial payment or denial notice to the provider or facility and then
30	30	pay a total amount to the provider or facility that is equal to the amount by which
31	31	the provider's or facility's rate exceeds the amount it received in cost sharing from
32	32	the enrollee; and 5) count any cost-sharing payment made by the enrollee for the
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37	37	ASSEMBLY BILL 784
38	38	emergency medical services toward any in-network deductible or out-of-pocket
39	39	maximum as if the cost-sharing payment was made for services provided by a
40	40	participating provider or facility. The provider or facility may not bill or hold liable
41	41	an enrollee of the plan for any amount for the emergency medical service that is more
42	42	than the cost-sharing amount that is calculated as described in the bill for the
43	43	emergency medical service.
44	44	For coverage of an item or service that is provided by a nonparticipating
45	45	provider in a participating facility, a plan must 1) not impose a cost-sharing
46	46	requirement for the item or service that is greater than the cost-sharing
47	47	requirement that would have been imposed if the item or service was provided by a
48	48	participating provider; 2) calculate the cost-sharing amount to be equal to the
49	49	amount that would have been charged if the service was provided by a participating
50	50	provider; 3) provide, within 30 days of the provider's bill, an initial payment or denial
51	51	notice to the provider and then pay a total amount to the provider that is equal to the
52	52	amount by which the provider's rate exceeds the amount it received in cost sharing
53	53	from the enrollee; and 4) count any cost-sharing payment made by the enrollee for
54	54	the items or services toward any in-network deductible or out-of-pocket maximum
55	55	as if the cost-sharing payment was made for items or services provided by a
56	56	participating provider. A nonparticipating provider providing an item or service in
57	57	a participating facility may not bill or hold liable an enrollee for more than the
58	58	cost-sharing amount unless the provider provides notice and obtains consent as
59	59	described in the bill. However, if the nonparticipating provider is providing an
60	60	ancillary item or service that is specified in the bill, and the commissioner of
61	61	insurance has not specifically allowed balance billing for that item or service by rule,
62	62	the nonparticipating provider providing the ancillary item or service in a
63	63	participating facility may not bill or hold liable an enrollee for more than the
64	64	cost-sharing amount.
65	65	Under the bill, a provider or facility that is entitled to a payment for an
66	66	emergency medical service or other item or service may initiate open negotiations
67	67	with the defined network plan, preferred provider plan, or self-insured
68	68	governmental health plan to determine the amount of payment. If the open
69	69	negotiation period terminates without determination of the payment amount, the
70	70	provider, facility, or plan may initiate the independent dispute resolution process as
71	71	specified by the commissioner of insurance. If an enrollee of a plan is a continuing
72	72	care patient, as defined in the bill, and is obtaining services from a participating
73	73	provider or facility, and the contract is terminated because of a change in the terms
74	74	of the participation of the provider or facility in the plan or the contract is terminated,
75	75	resulting in a loss of benefits under the plan, the plan must notify the enrollee of the
76	76	enrollee's right to elect to continue transitional care, provide the enrollee an
77	77	opportunity to notify the plan of the need for transitional care, and allow the enrollee
78	78	to continue to have the benefits provided under the plan under the same terms and
79	79	conditions as would have applied without the termination until either 90 days after
80	80	the termination notice date or the date on which the enrollee is no longer a continuing
81	81	care patient, whichever is earlier. If a continuing care patient would qualify for
82	82	continued care for a longer period under current law than specified in the bill, the - 3 -2023 - 2024 Legislature
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84	84	JPC:cdc
85	85	ASSEMBLY BILL 784
86	86	bill specifies that the continuing care patient may continue to receive coverage for
87	87	the longer period provided under current law.
88	88	This proposal may contain a health insurance mandate requiring a social and
89	89	financial impact report under s. 601.423, stats.
90	90	The people of the state of Wisconsin, represented in senate and assembly, do
91	91	enact as follows:
92	92	SECTION 1. 609.045 of the statutes is created to read:
93	93	609.045 Balance billing; emergency medical services. (1) DEFINITIONS.
94	94	In this section:
95	95	(a) “Emergency medical services” means emergency medical services for which
96	96	coverage is required under s. 632.85 (2) and includes emergency medical services
97	97	described under s. 632.85 (2) as if section 1867 of the federal Social Security Act
98	98	applied to an independent freestanding emergency department.
99	99	(b) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
100	100	preferred provider plan, as defined in s. 609.01 (4), that has a network of
101	101	participating providers and imposes on enrollees different requirements for using
102	102	providers that are not participating providers.
103	103	(c) “Self-insured governmental plan” means a self-insured health plan of the
104	104	state or a county, city, village, town, or school district that has a network of
105	105	participating providers and imposes on enrollees in the self-insured health plan
106	106	different requirements for using providers that are not participating providers.
107	107	(2) EMERGENCY MEDICAL SERVICES. A defined network plan, preferred provider
108	108	plan, or self-insured governmental plan that covers any benefits or services provided
109	109	in an emergency department of a hospital or emergency medical services provided
110	110	in an independent freestanding emergency department shall cover emergency
111	111	medical services in accordance with all of the following:
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133	133	SECTION 1 ASSEMBLY BILL 784
134	134	(a) The plan may not require a prior authorization determination.
135	135	(b) The plan may not deny coverage on the basis of whether or not the health
136	136	care provider providing the services is a participating provider or participating
137	137	emergency facility.
138	138	(c) If the emergency medical services are provided to an enrollee by a provider
139	139	or in a facility that is not a participating provider or participating facility, the plan
140	140	complies with all of the following:
141	141	1. The emergency medical services are covered without imposing on an enrollee
142	142	a requirement for prior authorization or any coverage limitation that is more
143	143	restrictive than requirements or limitations that apply to emergency medical
144	144	services provided by participating providers or in participating facilities.
145	145	2. Any cost-sharing requirement imposed on an enrollee for the emergency
146	146	medical services is no greater than the requirements that would apply if the
147	147	emergency medical services were provided by a participating provider or in a
148	148	participating facility.
149	149	3. Any cost-sharing amount imposed on an enrollee for the emergency medical
150	150	services is calculated as if the total amount that would have been charged for the
151	151	emergency medical services if provided by a participating provider or in a
152	152	participating facility is equal to the amount paid to the provider or facility that is not
153	153	a participating provider or participating facility as determined by the commissioner.
154	154	4. The plan does all of the following:
155	155	a. No later than 30 days after the provider or facility transmits to the plan the
156	156	bill for emergency medical services, sends to the provider or facility an initial
157	157	payment or a notice of denial of payment.
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184	184	SECTION 1
185	185	ASSEMBLY BILL 784
186	186	b. Pays to the provider or facility a total amount that, incorporating any initial
187	187	payment under subd. 4. a., is equal to the amount by which the rate for a provider
188	188	or facility that is not a participating provider or facility exceeds the cost-sharing
189	189	amount.
190	190	5. The plan counts any cost-sharing payment made by the enrollee for the
191	191	emergency medical services toward any in-network deductible or out-of-pocket
192	192	maximum applied by the plan in the same manner as if the cost-sharing payment
193	193	was made for emergency medical services provided by a participating provider or in
194	194	a participating facility.
195	195	(3) PROVIDER BILLING LIMITATION FOR EMERGENCY MEDICAL SERVICES; AMBULANCE
196	196	SERVICES. A provider of emergency medical services or a facility in which emergency
197	197	medical services are provided that is entitled to payment under sub. (2) may not bill
198	198	or hold liable an enrollee for any amount for the emergency medical service that is
199	199	more than the cost-sharing amount determined under sub. (2) (c) 3. for the
200	200	emergency service. A provider of ambulance services that is not a participating
201	201	provider under an enrollee's defined network plan, preferred provider plan, or
202	202	self-insured governmental plan may not bill or hold liable an enrollee for any
203	203	amount of the ambulance service that is more than the cost-sharing amount that the
204	204	enrollee would be charged if the provider of ambulance services was a participating
205	205	provider under the enrollee's plan.
206	206	(4) NONPARTICIPATING PROVIDER IN PARTICIPATING FACILITY. For items or services
207	207	other than emergency medical services that are provided to an enrollee of a defined
208	208	network plan, preferred provider plan, or self-insured governmental plan by a
209	209	provider that is not a participating provider but is providing services at a
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235	235	SECTION 1 ASSEMBLY BILL 784
236	236	participating facility, the plan shall provide coverage for the item or service in
237	237	accordance with all of the following:
238	238	(a) The plan may not impose on an enrollee a cost-sharing requirement for the
239	239	item or service that is greater than the cost-sharing requirement that would have
240	240	been imposed if the item or service was provided by a participating provider.
241	241	(b) Any cost-sharing amount imposed on an enrollee for the item or service is
242	242	calculated as if the total amount that would have been charged for the item or service
243	243	if provided by a participating provider is equal to the amount paid to the provider
244	244	that is not a participating provider as determined by the commissioner.
245	245	(c) No later than 30 days after the provider transmits the bill for services, the
246	246	plan shall send to the provider an initial payment or a notice of denial of payment.
247	247	(d) The plan shall make a total payment directly to the provider that provided
248	248	the item or service to the enrollee that, added to any initial payment described under
249	249	par. (c), is equal to the amount by which the out-of-network rate for the item or
250	250	service exceeds the cost-sharing amount.
251	251	(e) The plan counts any cost-sharing payment made by the enrollee for the item
252	252	or service toward any in-network deductible or out-of-pocket maximum applied by
253	253	the plan in the same manner as if the cost-sharing payment was made for the item
254	254	or service when provided by a participating provider.
255	255	(5) CHARGING FOR SERVICES BY NONPARTICIPATING PROVIDER; NOTICE AND CONSENT.
256	256	(a) Except as provided in par. (c), a provider of an item or service that is entitled to
257	257	payment under sub. (4) may not bill or hold liable an enrollee for any amount for the
258	258	item or service that is more than the cost-sharing amount calculated under sub. (4)
259	259	(b) for the item or service unless the nonparticipating provider provides notice and
260	260	obtains consent in accordance with all of the following:
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288	288	SECTION 1
289	289	ASSEMBLY BILL 784
290	290	1. The notice states that the provider is not a participating provider in the
291	291	enrollee's defined network plan, preferred provider plan, or self-insured
292	292	governmental plan.
293	293	2. The notice provides a good faith estimate of the amount that the
294	294	nonparticipating provider may charge the enrollee for the item or service involved,
295	295	including notification that the estimate does not constitute a contract with respect
296	296	to the charges estimated for the item or service.
297	297	3. The notice includes a list of the participating providers at the participating
298	298	facility that would be able to provide the item or service and notification that the
299	299	enrollee may be referred to one of those participating providers.
300	300	4. The notice includes information about whether or not prior authorization or
301	301	other care management limitations may be required before receiving an item or
302	302	service at the participating facility.
303	303	5. The notice clearly states that consent is optional and that the patient may
304	304	elect to seek care from an in-network provider.
305	305	6. The notice is worded in plain language.
306	306	7. The notice is available in languages other than English. The commissioner
307	307	shall identify languages for which the notice should be available.
308	308	8. The enrollee provides consent to the nonparticipating provider to be treated
309	309	by the nonparticipating provider, and the consent acknowledges that the enrollee
310	310	has been informed that the charge paid by the enrollee may not meet a limitation that
311	311	the enrollee's defined network plan, preferred provider plan, or self-insured
312	312	governmental plan places on cost sharing, such as an in-network deductible.
313	313	9. A signed copy of the consent described under subd. 8. is provided to the
314	314	enrollee.
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341	341	SECTION 1 ASSEMBLY BILL 784
342	342	(b) To be considered adequate, the notice and consent under par. (a) shall meet
343	343	one of the following requirements, as applicable:
344	344	1. If the enrollee makes an appointment for the item or service at least 72 hours
345	345	before the day on which the item or service is to be provided, any notice under par.
346	346	(a) shall be provided to the enrollee at least 72 hours before the day of the
347	347	appointment at which the item or service is to be provided.
348	348	2. If the enrollee makes an appointment for the item or service less than 72
349	349	hours before the day on which the item or service is to be provided, any notice under
350	350	par. (a) shall be provided to the enrollee on the day that the appointment is made.
351	351	(c) A provider of an item or service that is entitled to payment under sub. (4)
352	352	may not bill or hold liable an enrollee for any amount for an ancillary item or service
353	353	that is more than the cost-sharing amount determined under sub. (4) (b) for the item
354	354	or service, unless the commissioner specifies by rule that the provider may balance
355	355	bill for the ancillary item or service, if the item or service is any of the following:
356	356	1. Related to an emergency medical service.
357	357	2. Anesthesiology.
358	358	3. Pathology.
359	359	4. Radiology.
360	360	5. Neonatology.
361	361	6. An item or service provided by an assistant surgeon, hospitalist, or
362	362	intensivist.
363	363	7. A diagnostic service, including a radiology or laboratory service.
364	364	8. An item or service provided by a specialty practitioner that the commissioner
365	365	specifies by rule.
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392	392	SECTION 1
393	393	ASSEMBLY BILL 784
394	394	9. An item or service provided by a nonparticipating provider when there is no
395	395	participating provider that can furnish the item or service at the participating
396	396	facility.
397	397	(d) Any notice and consent provided under par. (a) may not extend to items or
398	398	services furnished as a result of unforeseen, urgent medical needs that arise at the
399	399	time the item or service is provided.
400	400	(e) Any consent provided under par. (a) shall be retained by the provider for no
401	401	less than 7 years.
402	402	(6) NOTICE BY PROVIDER OR FACILITY. Beginning no later than January 1, 2024,
403	403	a health care provider or health care facility shall make available, including posting
404	404	on a website, to enrollees in defined network plans, preferred provider plans, and
405	405	self-insured governmental plans notice of the requirements on a provider or facility
406	406	under subs. (3) and (5), of any other applicable state law requirements on the
407	407	provider or facility with respect to charging an enrollee for an item or service if the
408	408	provider or facility does not have a contractual relationship with the plan, and of
409	409	information on contacting appropriate state or federal agencies in the event the
410	410	enrollee believes the provider or facility violates any of the requirements under this
411	411	section or other applicable law.
412	412	(7) NEGOTIATION; DISPUTE RESOLUTION. A provider or facility that is entitled to
413	413	receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (4) (c) may
414	414	initiate, within 30 days of receiving the initial payment or notice of denial, open
415	415	negotiations with the defined network plan, preferred provider plan, or self-insured
416	416	governmental plan to determine a payment amount for an emergency medical
417	417	service or other item or service for a period that terminates 30 days after initiating
418	418	open negotiations. If the open negotiation period under this subsection terminates
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445	445	SECTION 1 ASSEMBLY BILL 784
446	446	without determination of a payment amount, the provider, facility, defined network
447	447	plan, preferred provider plan, or self-insured governmental plan may initiate,
448	448	within the 4 days beginning on the day after the open negotiation period ends, the
449	449	independent dispute resolution process as specified by the commissioner. If the
450	450	independent dispute resolution decision maker determines the payment amount,
451	451	the party to the independent dispute resolution process whose amount was not
452	452	selected shall pay the fees for the independent dispute resolution. If the parties to
453	453	the independent dispute resolution reach a settlement on the payment amount, the
454	454	parties to the independent dispute resolution shall equally divide the payment for
455	455	the fees for the independent dispute resolution.
456	456	(8) CONTINUITY OF CARE. (a) In this subsection:
457	457	1. “Continuing care patient” means an individual who is any of the following:
458	458	a. Undergoing a course of treatment for a serious and complex condition from
459	459	a provider or facility.
460	460	b. Undergoing a course of institutional or inpatient care from a provider or
461	461	facility.
462	462	c. Scheduled to undergo nonelective surgery, including receipt of postoperative
463	463	care, from a provider or facility.
464	464	d. Pregnant and undergoing a course of treatment for the pregnancy from a
465	465	provider or facility.
466	466	e. Terminally ill and receiving treatment for the illness from a provider or
467	467	facility.
468	468	2. “Serious and complex condition” means any of the following:
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494	494	SECTION 1
495	495	ASSEMBLY BILL 784
496	496	a. In the case of an acute illness, a condition that is serious enough to require
497	497	specialized medical treatment to avoid the reasonable possibility of death or
498	498	permanent harm.
499	499	b. In the case of a chronic illness or condition, a condition that is
500	500	life-threatening, degenerative, potentially disabling, or congenital and requires
501	501	specialized medical care over a prolonged period.
502	502	(b) If an enrollee is a continuing care patient and is obtaining items or services
503	503	from a participating provider or participating facility and the contract between the
504	504	defined network plan, preferred provider plan, or self-insured governmental plan
505	505	and the participating provider or participating facility is terminated or the coverage
506	506	of benefits that include the items or services provided by the participating provider
507	507	or participating facility are terminated by the plan, the plan shall do all of the
508	508	following:
509	509	1. Notify each enrollee of the termination of the contract or benefits and of the
510	510	right for the enrollee to elect to continue transitional care from the provider or facility
511	511	under this subsection.
512	512	2. Provide the enrollee an opportunity to notify the plan of the need for
513	513	transitional care.
514	514	3. Allow the enrollee to elect to continue to have the benefits provided under
515	515	the plan under the same terms and conditions as would have applied to the item or
516	516	service if the termination had not occurred for the course of treatment related to the
517	517	enrollee's status as a continuing care patient beginning on the date on which the
518	518	notice under subd. 1. is provided and ending 90 days after the date on which the
519	519	notice under subd. 1. is provided or the date on which the enrollee is no longer a
520	520	continuing care patient, whichever is earlier.
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547	547	SECTION 1 ASSEMBLY BILL 784
548	548	(c) The provisions of s. 609.24 apply to a continuing care patient to the extent
549	549	that s. 609.24 does not conflict with this subsection so as to limit the enrollee's rights
550	550	under this subsection.
551	551	(9) RULE MAKING. The commissioner may promulgate any rules necessary to
552	552	implement this section, including specifying the independent dispute resolution
553	553	process under sub. (7). The commissioner may promulgate rules to modify the list
554	554	of those items and services for which a provider may not balance bill under sub. (5)
555	555	(c).
556	556	(END)
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