Wisconsin 2023-2024 Regular Session

Wisconsin Senate Bill SB475 Compare Versions

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

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1	1	LRB-4132/1
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3	3	2023 - 2024 LEGISLATURE
4	4	2023 SENATE BILL 475
5	5	September 29, 2023 - Introduced by Senators TESTIN, BALLWEG, COWLES, L.
6	6	JOHNSON, LARSON and NASS, cosponsored by Representatives VANDERMEER,
7	7	BILLINGS, BRANDTJEN, BROOKS, DONOVAN, GUNDRUM, GUSTAFSON, MACCO,
8	8	MAGNAFICI, MAXEY, RETTINGER, ROZAR, SCHMIDT, SHANKLAND, WICHGERS and
9	9	WITTKE. Referred to Committee on Insurance and Small Business.
10	10	*AUTHORS SUBJECT TO CHANGE*
11	11	AN ACT to amend 632.85 (title) and 632.85 (3); and to create 632.85 (1) (d) and
12	12	632.851 of the statutes; relating to: prior authorization for coverage of
13	13	physical therapy, occupational therapy, speech therapy, chiropractic services,
14	14	and other services under health plans.
15	15	Analysis by the Legislative Reference Bureau
16	16	Generally, this bill requires and prohibits certain actions related to prior
17	17	authorization of physical therapy, occupational therapy, speech therapy, chiropractic
18	18	services, and other health care services by certain health plans. Under the bill, every
19	19	health plan, when requested to reauthorize coverage, must issue a decision on
20	20	reauthorization of coverage of a service for which prior authorization was previously
21	21	obtained within 48 hours or prior authorization is assumed to be granted. Health
22	22	plans are prohibited under the bill from requiring prior authorization for the first 12
23	23	physical therapy, occupational therapy, speech therapy, or chiropractic visits with no
24	24	duration of care limitation or for any nonpharmacologic management of pain
25	25	provided to individuals with chronic pain for the first 90 days of treatment. The bill
26	26	requires plans to reference the applicable policy and include an explanation to the
27	27	service provider and to the covered individual for any denial of coverage for or
28	28	reduction in covered services. Further, the bill requires plans to compensate
29	29	providers of physical therapy services, occupational therapy services, speech
30	30	therapy services, or chiropractic services as specified under the bill for data entry of
31	31	clinical information that is required by a utilization review organization or
32	32	utilization management organization acting on behalf of a plan. A plan must also
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37	37	JPC:cdc
38	38	SENATE BILL 475
39	39	impose copayment and coinsurance amounts on covered individuals for provided
40	40	services that are equivalent to copayment and coinsurance amounts imposed for
41	41	primary care services under the plan.
42	42	The bill also requires every utilization review organization and utilization
43	43	management organization that is providing review or management on behalf of a
44	44	health plan to provide to any licensed health care provider, upon request, all medical
45	45	evidence-based policy information that accompanies the algorithms that are used
46	46	to manage coverage and to operate and staff peer review activities with
47	47	Wisconsin-licensed health care providers holding credentials for the type of service
48	48	that is the subject of the review. The bill prohibits utilization review organizations
49	49	and utilization management organizations from using claims data as evidence of
50	50	outcomes for purposes of developing an algorithm to manage coverage or an approval
51	51	policy for coverage. Health plans to which the above requirements and prohibitions
52	52	apply are private health benefit plans and self-insured governmental health plans.
53	53	Additionally, the bill prohibits health care plans and self-insured
54	54	governmental health plans from requiring prior authorization for coverage of any
55	55	covered health care service that is incidental to a covered surgical service and
56	56	determined by the covered person's physician or other health care provider to be
57	57	medically necessary and of any covered urgent health care service as defined in the
58	58	bill. Current law prohibits health care plans and self-insured governmental health
59	59	plans from requiring prior authorization for coverage of emergency medical services.
60	60	This proposal may contain a health insurance mandate requiring a social and
61	61	financial impact report under s. 601.423, stats.
62	62	The people of the state of Wisconsin, represented in senate and assembly, do
63	63	enact as follows:
64	64	SECTION 1. 632.85 (title) of the statutes is amended to read:
65	65	632.85 (title) Coverage without prior authorization for treatment of an
66	66	emergency medical condition; other conditions.
67	67	SECTION 2. 632.85 (1) (d) of the statutes is created to read:
68	68	632.85 (1) (d) “Urgent health care service” means a health care service for
69	69	which the application of the time for making a nonexpedited request for prior
70	70	authorization, in the opinion of a physician or other health care provider with
71	71	knowledge of the covered person's medical condition, could do any of the following:
72	72	1. Seriously jeopardize the life or health of the covered person or the ability of
73	73	that person to regain maximum function.
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86	86	SECTION 2
87	87	SENATE BILL 475
88	88	2. Subject the covered person to severe pain that cannot be adequately
89	89	managed without the care or treatment that is the subject of the utilization review.
90	90	SECTION 3. 632.85 (3) of the statutes is amended to read:
91	91	632.85 (3) A health care plan or a self-insured health plan that is required to
92	92	provide the coverage under sub. (2) may not require prior authorization for the
93	93	provision or coverage of the emergency medical services specified in sub. (2), any
94	94	covered health care service that is incidental to a covered surgical service and
95	95	determined by the covered person's physician or other health care provider to be
96	96	medically necessary, or any covered health care service that is an urgent health care
97	97	service.
98	98	SECTION 4. 632.851 of the statutes is created to read:
99	99	632.851 Prior authorization; general; physical, occupational, speech
100	100	therapy and chiropractic care. (1) In this section:
101	101	(a) “Episode of care” means treatment for a new or recurring condition for which
102	102	an insured has not been treated within the previous 90 days.
103	103	(b) “Health benefit plan” has the meaning given in s. 632.745 (11).
104	104	(c) “Self-insured health plan” means a self-insured health plan of the state or
105	105	a county, city, village, town, or school district.
106	106	(2) A health benefit plan or self-insured health plan that uses prior
107	107	authorization procedures may not do any of the following:
108	108	(a) Require prior authorization for the first 12 physical therapy, occupational
109	109	therapy, speech therapy, or chiropractic visits with no duration of care limitation. A
110	110	plan may require prior authorization for visits after the initial 12 physical therapy,
111	111	occupational therapy, speech therapy, or chiropractic visits of an episode of care for
112	112	a specific condition.
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139	139	SECTION 4 SENATE BILL 475
140	140	(b) Require prior authorization for any nonpharmacologic management of pain
141	141	provided to individuals with chronic pain for the first 90 days of treatment.
142	142	(3) A health benefit plan or self-insured health plan that provides coverage of
143	143	physical therapy services, occupational therapy services, speech therapy services, or
144	144	chiropractic services shall do all of the following with respect to such services:
145	145	(a) Reference the applicable policy and include an explanation to the service
146	146	provider and, in plain language, to the covered individual for any denial of coverage
147	147	or reduction in covered services.
148	148	(b) Compensate providers of physical therapy services, occupational therapy
149	149	services, speech therapy services, or chiropractic services at 50 percent of the current
150	150	procedure terminology therapeutic exercise rate for a therapeutic physical therapy
151	151	procedure on one or more areas each lasting 15 minutes for each quarter hour of data
152	152	entry of clinical information that is required by a utilization review organization or
153	153	utilization management organization acting on behalf of a plan. The physical
154	154	therapy service provider, occupational therapy service provider, speech therapy
155	155	service provider, or chiropractic service provider shall invoice the utilization review
156	156	organization or utilization management organization monthly to obtain the
157	157	compensation described under this paragraph or the health benefit plan or
158	158	self-insured health plan shall increase reimbursement to physical therapy service
159	159	providers, occupational therapy service provider, speech therapy service provider, or
160	160	chiropractic service providers commensurate with increased administrative
161	161	expenses.
162	162	(c) Impose copayment and coinsurance amounts on covered individuals for the
163	163	services that are equivalent to copayment and coinsurance amounts imposed on
164	164	covered individuals for primary care services under the plan.
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190	190	LRB-4132/1
191	191	JPC:cdc
192	192	SECTION 4
193	193	SENATE BILL 475
194	194	(4) Every health benefit plan or self-insured health plan when requested to
195	195	reauthorize coverage of a service for which prior authorization was previously
196	196	obtained shall issue the decision on reauthorization within 48 hours of the request.
197	197	If a plan does not issue a decision on reauthorization described under this subsection
198	198	within 48 hours, prior authorization is assumed to be granted for the service.
199	199	(5) Every utilization review organization and utilization management
200	200	organization that is providing review or management on behalf of a health benefit
201	201	plan or self-insured health plan shall do all of the following:
202	202	(a) Provide to any licensed health care provider upon request all medical
203	203	evidence-based policy information that accompanies the algorithms that are used
204	204	to manage coverage. A utilization review organization or utilization management
205	205	organization may not use claims data as evidence of outcomes for purposes of
206	206	developing an algorithm to manage coverage or an approval policy for coverage.
207	207	(b) Operate and staff peer review activities with health care providers that are
208	208	licensed in this state and hold credentials for the type of service that is the subject
209	209	of the review.
210	210	(END)
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