Under current law, as affected by 2007 Wisconsin Act 20 (the biennial budget
act), if an applicant for Medical Assistance (MA) is determined to be eligible for MA
retroactively (for three months) and a provider bills the applicant directly for
services and benefits rendered during the retroactive period, the provider must
submit MA claims for those services and benefits that are covered under MA. Upon
receiving MA payment under the claims, the provider must reimburse the MA
recipient, or other person who made the prior payment on behalf of the recipient, for
services provided to the recipient during the retroactive eligibility period, by the
amount of the prior payment made.

This bill restricts payment that a health care provider, as defined in the bill,
may accept from certain patients who are uninsured or who do not have public
coverage (as defined in the bill). If the patient, within 90 days after receiving a health
care service, diagnostic test, procedure or the first treatment or visit of a course of

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treatment as part of a health care service, obtains coverage from an insurer or a
self-insured health plan under a contract for not less than one year, the health care
provider must accept, as payment from the patient for the service, test, or procedure
no more than the insurer's or plan's payment amount for that service, test, or
procedure. However, the patient may be liable to the health care provider for
out-of-pocket costs, finance charges, and collection costs incurred that would not
have been covered under the patient's coverage. The insurer or self-insured health
plan that provides coverage must provide to the patient a dollar estimate of the
applicable payment amount for the service, test, or procedure the patient received.
A health care provider must provide to a patient who is uninsured or does not have
public coverage, at the time the health care service, test, or procedure is provided or
after the first treatment or visit of a course of treatment, information about this
restriction on payment and information about the restriction on acceptance of
patient payment for MA applicants who receive retroactive eligibility. Also, under
the bill, if a health care provider does not accept patients who are covered by a
particular insurer, if a health care service, diagnostic test, or procedure is not covered
under a patient's health care plan, or if the patient's health care plan only covers
services provided by health care providers participating in the plan and this health
care provider is not a participating provider, the health care provider shall accept,
as payment from the patient for the service, test, or procedure provided to the
patient, the average rate paid by insurers or self-insured health plans for the
service, test, or procedure or a rate less than the average rate.

Under the bill, if a patient is recommended, referred for service, or prescribed
a health care service (including any applicable course of treatment), diagnostic test,
or procedure for which the charge exceeds $500 or any higher amount that the
Department of Health and Family Services (DHFS) promulgates by rule (the
minimum cost), the health care provider must provide an estimate of the charge to
the patient, whether insured or uninsured, or the patient's agent who requests it.
The estimate of the charge must be provided at the time of scheduling of the health
care service, diagnostic test, procedure, or course of treatment, or within ten business
days of the request, whichever is later. The bill specifies numerous requirements for
the estimate of charge, except that, in lieu of several of the requirements, a health
care provider may provide to the patient or his or her agent an estimate of charge that
is a single fixed price estimate of the total cost of the health care service, diagnostic
test, or procedure.

The bill requires DHFS, by rule, biennially to adjust the dollar amount that is
specified for minimum cost and specifies a procedure, using the consumer price
index, by which the adjusted dollar amount must be calculated. DHFS may
promulgate the amount as an emergency rule without providing a finding of
emergency or complying with certain other standards for promulgating emergency
rules.

The bill requires a self-insured health plan of the state or a county, city, village,
town, or school district, or an insurer that provides health care coverage under a
health care plan, including a defined network plan or a sickness care plan operated
by a cooperative association, to provide to an insured under the health care plan or

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an enrollee under the self-insured health plan, any of the following if requested by
the insured or enrollee: 1) a description of the coverage, including benefits and
cost-sharing requirements, under the health care plan or self-insured health plan;
2) a description of any pre-certification or other requirements that an insured or
enrollee must complete before any care is approved by the insurer or self-insured
health plan; and 3) a summary of the insured's or enrollee's coverage with respect to
a specific medical service or course of treatment. The summary of coverage is based
on information relating to an estimate of a charge for a medical service or course of
treatment that was provided by a provider or group of providers to the insured or
enrollee and must include an estimate of the total out-of-pocket costs that the
insured or enrollee may incur, an estimate of the amount that the insurer or
self-insured health plan has paid to the provider or providers, any limits on what the
insurer or self-insured health plan will pay if the service or course of treatment is
received from a nonparticipating or out-of-network provider, and any discounts that
the insurer or self-insured health plan is willing to offer the insured or enrollee if the
service or course of treatment is received from a different provider.