AB872,13,220 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be
21exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
22601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
23631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85,
24632.853, 632.855, 632.87 (2m), (3), (4), and (5), and (6), 632.895 (5) and (9) to (15),

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1632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring
2association shall:

AB872,13,5 4609.71 Disclosure of payments. Limited service health organizations,
5preferred provider plans, and defined network plans are subject to s. 632.798.

AB872,13,7 7632.798 Disclosure of information. (1) Definitions. In this section:

AB872,13,108 (a) "Cost-sharing requirements" means copayments, deductibles, coinsurance
9percentages, and any other cost-sharing mechanisms that apply under a health care
10plan or self-insured health plan.

AB872,13,1111 (b) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.

AB872,13,1312 (c) "Insured" means a person covered under a health care plan offered by an
13insurer or an enrollee under a self-insured health plan.

AB872,13,1714 (d) "Insured's agent" means a parent, guardian, or legal custodian of an insured
15who is a minor child; the spouse of an insured; an agent of an insured under a valid
16power of attorney for health care; a guardian of the person, as defined in s. 54.01 (12),
17of an insured; or anyone authorized by an insured to act as his or her agent.

AB872,13,2518 (e) "Insurer" means an insurer that is authorized to do business in this state,
19in one or more lines of insurance that includes health insurance, and that provides
20coverage, excluding public coverage, of health care expenses under health care plans
21covering individuals or groups in this state. The term includes a health maintenance
22organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s.
23609.01 (4), an insurer operating as a cooperative association organized under ss.
24185.981 to 185.985, and a limited service health organization, as defined in s. 609.01
25(3).

AB872,14,1

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1(f) "Participating" has the meaning given in s. 609.01 (3m).

AB872,14,22 (g) "Provider" means a health care provider, as defined in s. 146.81 (1).

AB872,14,73 (h) "Public coverage" means coverage for health care expenses that is funded
4in whole or in part under any state-assisted or federally assisted program, including
5Medical Assistance under subch. IV of ch. 49 and Medicare under 42 USC 1395 to
61395hhh, the average paid rate of which is lower than an insurer's average paid rate
7for the same medical service.

AB872,14,88 (i) "Self-insured health plan" has the meaning given in s. 632.745 (24).

AB872,14,10 9(2) Information required. An insurer or self-insured health plan shall provide
10any of the following information if requested by an insured or an insured's agent:

AB872,14,1211 (a) A description of the coverage, including benefits and cost-sharing
12requirements, under the insured's health care plan or self-insured health plan.

AB872,14,1513 (b) A description of pre-certification or other requirements, if any, that an
14insured must complete before any care is approved by the insurer or self-insured
15health plan.

AB872,14,1916 (c) Based on the information relating to an estimate of the charge that was
17provided to the insured or insured's agent under s. 146.903 (3) (a), a summary of the
18insured's coverage with respect to a specific medical service or course of treatment,
19including all of the following information:

AB872,14,2220 1. The estimated total and type of out-of-pocket costs that the insured may
21incur, including deductibles, copayments, coinsurance, and items and other charges
22that are not covered by the insurer or self-insured health plan.

AB872,15,223 2. An estimate of the amount that the insurer or self-insured health plan paid
24to a provider or providers for the specific medical procedure or course of treatment.
25The estimate under this subdivision may provide the payment amount or rate in such

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1a way that protects the insurer's proprietary pricing, but shall be a reasonably close
2estimate of the actual amount or rate paid.

AB872,15,113 3. Any limits on what the insurer or self-insured health plan will pay if the
4service or course of treatment is received from a provider that is not a participating
5provider. If the insured provides to the insurer or self-insured health plan the
6applicable medical code or codes for the service or course of treatment provided or
7proposed to be provided by a provider or providers that are not participating, the
8insurer or self-insured health plan shall inform the insured if the cost of the service
9or course of treatment exceeds the allowable charge under the insurer's or
10self-insured health plan's guidelines for payment for the service or course of
11treatment under the insured's health care plan or self-insured health plan.

AB872,15,1412 4. Any discounts or financial incentives that the insurer or self-insured health
13plan is willing to offer the insured, including incentives for the insured to obtain care
14or a course of treatment from a different provider.

AB872,15,1715 5. That the information in the summary is based on the information relating
16to the estimate of the charge that was provided to the insured or insured's agent
17under s. 146.903 (3) (a).

AB872,15,1918 6. That the information in the summary represents only an estimate and is not
19a legally binding contract or guarantee of the amounts provided in the summary.

AB872,15,22 20(3) General provisions. (a) The information under sub. (2) may be provided
21to the insured in writing, orally, or electronically, whichever is preferred by the
22insured.

AB872,15,2423 (b) The insurer or self-insured health plan shall make a good faith effort to
24provide accurate information to the insured under sub. (2).