AB539,12,96 185.981 (4t) A sickness care plan operated by a cooperative association is
7subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.798,
8632.85, 632.853, 632.855, 632.87 (2m), (3), (4), and (5), and (6), 632.895 (10) to (15),
9and 632.897 (10) and chs. 149 and 155.

AB539,12,1711 185.983 (1) (intro.) Every such voluntary nonprofit sickness care plan shall be
12exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
13601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
14631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798, 632.85,
15632.853, 632.855, 632.87 (2m), (3), (4), and (5), and (6), 632.895 (5) and (9) to (15),
16632.896, and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring
17association shall:

AB539,12,20 19609.71 Disclosure of payments. Limited service health organizations,
20preferred provider plans, and defined network plans are subject to s. 632.798.

AB539,12,22 22632.798 Disclosure of information. (1) Definitions. In this section:

AB539,12,2523 (a) "Cost-sharing requirements" means copayments, deductibles, coinsurance
24percentages, and any other cost-sharing mechanisms that apply under a health care
25plan or self-insured health plan.

AB539,13,1

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

AB539,13,32 (c) "Insured" means a person covered under a health care plan offered by an
3insurer or an enrollee under a self-insured health plan.

AB539,13,74 (d) "Insured's agent" means a parent, guardian, or legal custodian of an insured
5who is a minor child; the spouse of an insured; an agent of an insured under a valid
6power of attorney for health care; a guardian of the person, as defined in s. 54.01 (12),
7of an insured; or anyone authorized by an insured to act as his or her agent.

AB539,13,158 (e) "Insurer" means an insurer that is authorized to do business in this state,
9in one or more lines of insurance that includes health insurance, and that provides
10coverage, excluding public coverage, of health care expenses under health care plans
11covering individuals or groups in this state. The term includes a health maintenance
12organization, as defined in s. 609.01 (2), a preferred provider plan, as defined in s.
13609.01 (4), an insurer operating as a cooperative association organized under ss.
14185.981 to 185.985, and a limited service health organization, as defined in s. 609.01
15(3).

AB539,13,1616 (f) "Participating" has the meaning given in s. 609.01 (3m).

AB539,13,1717 (g) "Provider" means a health care provider, as defined in s. 146.81 (1).

AB539,13,2218 (h) "Public coverage" means coverage for health care expenses that is funded
19in whole or in part under any state-assisted or federally assisted program, including
20Medical Assistance under subch. IV of ch. 49 and Medicare under 42 USC 1395 to
211395hhh, the average paid rate of which is lower than an insurer's average paid rate
22for the same medical service.

AB539,13,2323 (i) "Self-insured health plan" has the meaning given in s. 632.745 (24).

AB539,13,25 24(2) Information required. An insurer or self-insured health plan shall provide
25any of the following information if requested by an insured or an insured's agent:

AB539,14,2

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1(a) A description of the coverage, including benefits and cost-sharing
2requirements, under the insured's health care plan or self-insured health plan.

AB539,14,53 (b) A description of pre-certification or other requirements, if any, that an
4insured must complete before any care is approved by the insurer or self-insured
5health plan.

AB539,14,96 (c) Based on the information relating to an estimate of the charge that was
7provided to the insured or insured's agent under s. 146.903 (3) (a), a summary of the
8insured's coverage with respect to a specific medical service or course of treatment,
9including all of the following information:

AB539,14,1210 1. The estimated total and type of out-of-pocket costs that the insured may
11incur, including deductibles, copayments, coinsurance, and items and other charges
12that are not covered by the insurer or self-insured health plan.

AB539,14,1713 2. An estimate of the amount that the insurer or self-insured health plan paid
14to a provider or providers for the specific medical procedure or course of treatment.
15The estimate under this subdivision may provide the payment amount or rate in such
16a way that protects the insurer's proprietary pricing, but shall be a reasonably close
17estimate of the actual amount or rate paid.

AB539,15,218 3. Any limits on what the insurer or self-insured health plan will pay if the
19service or course of treatment is received from a provider that is not a participating
20provider. If the insured provides to the insurer or self-insured health plan the
21applicable medical code or codes for the service or course of treatment provided or
22proposed to be provided by a provider or providers that are not participating, the
23insurer or self-insured health plan shall inform the insured if the cost of the service
24or course of treatment exceeds the allowable charge under the insurer's or

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1self-insured health plan's guidelines for payment for the service or course of
2treatment under the insured's health care plan or self-insured health plan.

AB539,15,53 4. Any discounts or financial incentives that the insurer or self-insured health
4plan is willing to offer the insured, including incentives for the insured to obtain care
5or a course of treatment from a different provider.

AB539,15,86 5. That the information in the summary is based on the information relating
7to the estimate of the charge that was provided to the insured or insured's agent
8under s. 146.903 (3) (a).

AB539,15,109 6. That the information in the summary represents only an estimate and is not
10a legally binding contract or guarantee of the amounts provided in the summary.

AB539,15,13 11(3) General provisions. (a) The information under sub. (2) may be provided
12to the insured in writing, orally, or electronically, whichever is preferred by the
13insured.

AB539,15,1514 (b) The insurer or self-insured health plan shall make a good faith effort to
15provide accurate information to the insured under sub. (2).