AB872,5,74 (e) "Course of treatment" means, as part of a health care service, the
5management and care, including related therapy and rehabilitation, of a patient
6over time for the purpose of combating disease or disorder or temporarily or
7permanently relieving symptoms.
AB872,5,88 (f) "Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
AB872,5,109 (g) "Health care provider" has the meaning given in s. 146.81 (1) and includes
10a clinic and an ambulatory surgery center.
AB872,5,1311 (h) "Health care service, diagnostic test, or procedure" includes physical
12therapy, speech therapy, occupational therapy, chiropractic treatment, or mental
13therapy, but does not include a prescription drug.
AB872,5,1514 (i) "Insured" means covered under a health care plan offered by an insurer or
15under a self-insured health plan.
AB872,5,2316 (j) "Insurer" means an insurer that is authorized to do business in this state,
17in one or more lines of insurance that includes health insurance, and that provides
18coverage, excluding public coverage, of health care expenses under health care plans
19covering individuals or groups in this state. The term includes a health maintenance
20organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s.
21609.01 (4), an insurer operating as a cooperative association organized under ss.
22185.981 to 185.985, and a limited service health organization, as defined in s. 609.01
23(3).
AB872,5,2524 (k) "Medical Assistance" means aid provided under subch. IV of ch. 49, other
25than aid under s. 49.471.
AB872,6,2
1(L) "Medicare" means coverage under Part A or Part B of Title XVIII of the
2federal social security act, 42 USC 1395 to 1395hhh.
AB872,6,43 (m) "Mental therapy" includes services and treatment for mental illness,
4developmental disability, alcohol and other drug abuse, and drug dependence.
AB872,6,65 (n) "Minimum cost" means $500 or any higher amount that is specified by the
6department by rule.
AB872,6,107 (p) "Patient's agent" means the parent, guardian, or legal custodian of a minor
8patient; the spouse of a patient; an agent of a patient under a valid power of attorney
9for health care; a guardian of the person, as defined in s. 54.01 (12) of a patient; or
10any individual who is authorized by the patient to act as his or her agent.
AB872,6,1111 (q) "Prescription drug" has the meaning given in s. 450.01 (20).
AB872,6,1712 (r) "Public coverage" means coverage for health care expenses that is funded
13in whole or in part under any state-assisted or federally assisted program other than
14BadgerCare Plus under s. 49.471, including Medical Assistance and Medicare, for
15which the average reimbursement rate for a health care service, diagnostic test, or
16procedure is lower than an insurer's or self-insured health plan's average paid rate
17for the identical service, test, or procedure.
AB872,6,1818 (s) "Self-insured health plan" has the meaning given in s. 632.745 (24).
AB872,7,4 19(2) (a) 1. If a patient is not insured or does not have public coverage at the time
20he or she first receives a particular health care service, diagnostic test, or procedure
21or the first treatment or visit of a course of treatment and, within 90 days after
22receipt of the service, test, procedure, or treatment, obtains from an insurer or a
23self-insured health plan coverage that is under a contract for not less than one year,
24the health care provider shall accept, as payment from the patient for the service,
25test, or procedure provided to the patient, no more than the insurer's or plan's

1payment amount for that service, test, or procedure, except that the patient may be
2liable to the health care provider for any out-of-pocket costs, finance charges, and
3collection costs incurred that would not have been covered under the patient's
4coverage.
AB872,7,95 2. The health care provider of a patient who is not insured or who does not have
6public coverage at the time that a health care service, diagnostic test, or procedure
7is provided or after the first treatment or visit of a course of treatment shall inform
8the patient of the requirement under subd. 1. and of the provider's reimbursement
9requirement for a recipient of Medical Assistance under s. 49.49 (3m) (a) 2.
AB872,7,1310 3. The insurer or self-insured health plan that provides coverage specified
11under subd. 1. shall provide to the patient a dollar estimate of the insurer's or plan's
12applicable payment amount for the health care service, diagnostic test, or procedure
13received by the patient, as specified under subd. 1.
AB872,7,2114 (b) If a health care provider does not accept patients who are covered by a
15particular insurer, if a health care service, diagnostic test, or procedure is not covered
16under a patient's health care plan, or the patient's health care plan only covers
17services provided by health care providers participating in the patient's health care
18plan and this health care provider is not a participating provider, the health care
19provider shall accept, as payment from the patient for the service, test, or procedure
20provided to the patient, the average rate paid by insurers or self-insured health
21plans for the service, test, or procedure or a rate less than the average rate.
AB872,8,3 22(3) (a) If a patient who is insured or is not insured is recommended to, referred
23to, or is under the care of a health care provider or group of health care providers for
24a health care service, including any applicable course of treatment, or diagnostic test
25or procedure for which the charge exceeds the minimum cost, and if the patient or

1the patient's agent requests an estimate of the charge, the health care provider or
2group of health care providers, if applicable, shall provide the patient or the patient's
3agent with an estimate of the charge.
AB872,8,84 (b) Except as provided in par. (c) 2., for an estimate of the charge that is
5provided under par. (a), the health care provider or group of health care providers,
6if applicable, shall provide the following, as applicable, at the time of scheduling of
7the health care service, diagnostic test, procedure, or course of treatment or within
810 business days of the request, whichever is later:
AB872,8,109 1. For an inpatient surgical procedure and course of treatment, an estimate of
10the charge that shall include all of the following:
AB872,8,1311 a. The reasonably anticipated services of health care providers who will likely
12provide health care services, during and after the surgical procedure and during any
13related course of treatment.
AB872,8,1514 b. The reasonably anticipated total charge for hospitalization, daily charge for
15hospitalization, and number of days of hospital stay.
AB872,8,1716 2. For an outpatient surgical procedure and course of treatment, an estimate
17of the charge that shall include the reasonably anticipated total charge.
AB872,8,2118 3. For a nonsurgical hospital procedure and course of treatment, an estimate
19of the charge that shall include the reasonably anticipated services of health care
20providers who will likely provide health care services during and after the procedure
21and any related course of treatment.
AB872,8,2422 4. For physical therapy, speech therapy, occupational therapy, chiropractic
23treatment, or mental therapy, an estimate of the charge that shall include all of the
24following:
AB872,9,5
1a. A proposed treatment plan that describes the number and frequency of visits
2of a course of treatment and the anticipated charges for the course of treatment. If
3the course of treatment is anticipated to exceed 6 months and if the patient or the
4patient's agent so requests, the health care provider shall provide an estimate of the
5charge and course of treatment plan for each anticipated 6 month period.
AB872,9,76 b. Objective quality data that is related to the health outcome of the proposed
7course of treatment, if the health care provider has made public the data.
AB872,9,98 (c) 1. All of the following applies to an estimate of the charge provided under
9this subsection:
AB872,9,1210 a. The estimate of the charge shall represent the good-faith effort of a health
11care provider or group of health care providers, if applicable, to provide accurate
12information to the patient or the patient's agent.
AB872,9,1713 b. The estimate of the charge shall inform the patient of his or her
14responsibilities in complying with any medical requirements for the patient that are
15associated with any health care service, diagnostic test, or procedure proposed; and
16the potential of cost variances that are due to factors that cannot reasonably be
17anticipated.
AB872,9,1918 c. The estimate of the charge shall indicate how the health status of the patient
19may contribute to any charge variances that may reasonably be anticipated.
AB872,9,2320 d. The estimate of the charge shall include any discounts or financial incentives
21the health care provider or group of health care providers, if applicable, are willing
22to offer to the patient for obtaining a health care service, diagnostic test, or procedure
23that is provided by the health care provider or group of health care providers.
AB872,9,2524 e. The estimate of the charge shall include a description of the health care
25service, diagnostic test, or procedure that includes the appropriate medical code or

1codes that will enable the patient or patient's agent to obtain applicable coverage
2payment information under s. 632.798 from an insurer or self-insured health plan.
AB872,10,63 f. The estimate of the charge shall include the identity of the health care
4provider or the individual identities of the group of health care providers, if
5applicable, and the address of the applicable facility with which each health care
6provider is associated.
AB872,10,87 g. The estimate of the charge may, if requested by the patient or the patient's
8agent, be issued electronically.
AB872,10,109 h. The estimate of the change is not a binding contract upon the parties and is
10not a guarantee that the amounts estimated will be charged.
AB872,10,1411 2. In lieu of the requirements under par. (b), a health care provider or group of
12health care providers, if applicable, may provide to the patient or the patient's agent
13an estimate of the charge that is a single fixed-price estimate of the total cost of the
14health care service, diagnostic test, or procedure.
AB872,10,1615 3. All of the following applies to an estimate of the charge provided under this
16subsection for a patient who is insured:
AB872,10,2117 a. The health care provider or group of health care providers, if applicable, may
18provide the average paid rate paid by insurers and self-insured health plans, the
19charged rate billed to insurers and plans, or a rate that is lower than the charged rate
20billed to private insurers, if each rate that is provided is clearly labeled in the
21estimate of the charge.
AB872,10,2422 b. The estimate of the charge shall contain language that encourages the
23patient to review the estimate carefully and to contact his or her insurer or
24self-insured health plan for specific coverage information.
AB872,11,2
14. All of the following applies to an estimate of the charge provided under this
2subsection for a patient who is not insured:
AB872,11,113 a. If the health care provider determines, on the basis of preliminary
4information, that the patient is eligible for Medical Assistance or is eligible for but
5not enrolled in Medicare and the health care provider accepts recipients of Medical
6Assistance or beneficiaries of Medicare, the estimate of the charge shall include the
7average paid rate paid by insurers and self-insured health plans or a rate lower than
8that rate; shall contain language that encourages the patient to review the estimate
9carefully and to apply for Medical Assistance or enroll in Medicare, as applicable; and
10shall inform the patient or the patient's agent of the requirements of s. 49.49 (3m)
11(a) 2.
AB872,11,1812 b. If the health care provider cannot determine if the patient is eligible for
13Medical Assistance or Medicare, the estimate of the charge shall include the average
14paid rate paid by insurers and self-insured health plans or a rate lower than that
15rate; shall contain language that encourages the patient to review the estimate
16carefully and to obtain insurance coverage; and shall inform the patient or the
17patient's agent of the terms and conditions under which the average paid rate or
18another paid rate may be applicable.
AB872,11,21 19(4) (a) In this subsection, "consumer price index" means the average of the
20consumer price index over each 12-month period, all items, U. S. city average, as
21determined by the bureau of labor statistics of the U. S. department of labor.
AB872,12,1122 (b) The department shall, by rule, biennially adjust the dollar amount that is
23specified for minimum cost under sub. (1) (n) by calculating any percentage
24difference between the consumer price index for the 12-month period ending on
25December 31 of the most recent odd-numbered year and the consumer price index

1for the 12-month period ending on December 31 of the next most recent
2odd-numbered year and applying that percentage difference, if any, to the
3most-recently specified dollar amount for minimum cost under this subsection or
4sub. (1) (n). If a percentage difference exists, the department shall by rule prescribe
5a revised dollar amount, rounded to the nearest $50 increment, that reflects the
6percentage difference, which amount shall be in effect until a subsequent rule is
7promulgated under this subsection. Notwithstanding s. 227.24 (1) (a), (2) (b), or (3),
8the department is not required to provide evidence that promulgating a rule under
9this subsection as an emergency rule is necessary for the preservation of the public
10peace, health, safety, or welfare and is not required to provide a finding of emergency
11for a rule promulgated under this subsection.
AB872, s. 6 12Section 6. 185.981 (4t) of the statutes, as affected by 2007 Wisconsin Act 36,
13is amended to read:
AB872,12,1714 185.981 (4t) A sickness care plan operated by a cooperative association is
15subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.798,
16632.85, 632.853, 632.855, 632.87 (2m), (3), (4), and (5), and (6), 632.895 (10) to (15),
17and 632.897 (10) and chs. 149 and 155.
AB872, s. 7 18Section 7. 185.983 (1) (intro.) of the statutes, as affected by 2007 Wisconsin
19Act 36
, is amended to read:
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),

1632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring
2association shall:
AB872, s. 8 3Section 8. 609.71 of the statutes is created to read:
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, s. 9 6Section 9. 632.798 of the statutes is created to read:
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
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

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).
AB872, s. 10 25Section 10. Initial applicability.
AB872,16,7
1(1) Disclosure of information. If a health care plan or a governmental
2self-insured health plan that is in effect on the effective date of this subsection, or
3a contract or agreement between a health care provider and a health care plan that
4is in effect on the effective date of this subsection, contains a provision that is
5inconsistent with this act, this act first applies to that health care plan,
6governmental self-insured health plan, or contract or agreement on the date on
7which it is modified, extended, or renewed.
AB872, s. 11 8Section 11. Effective date.
AB872,16,109 (1) This act takes effect on the first day of the 19th month beginning after
10publication.
AB872,16,1111 (End)
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