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AB1218: Bill Text
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2025 - 2026 LEGISLATURE
LRB-6585/1
JPC/EKL/SWB:emw
2025 ASSEMBLY BILL 1218
March 19, 2026 - Introduced by Representatives
Prado
,
Brown
,
Clancy
,
Emerson
,
Goodwin
,
Madison
,
McCarville
,
Sinicki
,
Tenorio
and
Subeck
, cosponsored by Senators
Roys
,
Larson
,
Ratcliff
and
Smith
. Referred to Committee on Insurance.
AB1218,1,3
1
An Act
to create
609.04 and 609.24 (5) of the statutes;
relating to:
preventing
2
surprise bills for emergency medical services and other items and services
3
under health insurance policies and plans.
Analysis by the Legislative Reference Bureau
This bill requires defined network plans, such as health maintenance organizations, and certain preferred provider plans and self-insured governmental plans that cover benefits or services provided in either an emergency department of a hospital or an independent freestanding emergency department to cover emergency medical services without requiring a prior authorization determination and without regard to whether the health care provider providing the emergency medical services is a participating provider or facility. If the emergency medical services for which coverage is required are provided by a nonparticipating provider, the plan must 1) not impose a prior authorization requirement or other limitation that is more restrictive than if the service was provided by a participating provider; 2) not impose cost sharing on an enrollee that is greater than the cost sharing required if the service was provided by a participating provider; 3) calculate the cost-sharing amount to be equal to the recognized amount specified under federal law; 4) provide, within 30 days of the provider’s or facility’s bill, an initial payment or denial notice to the provider or facility and then pay a total amount to the provider or facility that is equal to the amount by which an out-of-network rate exceeds the amount it received in cost sharing from the enrollee; and 5) count any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for services provided by a participating provider or facility.
For coverage of an item or service that is provided by a nonparticipating provider in a participating facility, a plan must 1) not impose a cost-sharing requirement for the item or service that is greater than the cost-sharing requirement that would have been imposed if the item or service was provided by a participating provider; 2) calculate the cost-sharing amount to be equal to the recognized amount specified under federal law; 3) provide, within 30 days of the provider’s bill, an initial payment or denial notice to the provider and then pay a total amount to the provider that is equal to the amount by which the out-of-network rate exceeds the amount it received in cost sharing from the enrollee; and 4) count any cost-sharing payment made by the enrollee for the items or services toward any in-network deductible or out-of-pocket maximum as if the cost-sharing payment was made for items or services provided by a participating provider. A nonparticipating provider providing an item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount unless the provider provides notice and obtains consent as described in the bill. However, if the nonparticipating provider is providing an ancillary item or service that is specified in the bill, and the commissioner of insurance has not specifically allowed providers to bill or hold an enrollee liable for that item or service by rule, the nonparticipating provider providing the ancillary item or service in a participating facility may not bill or hold liable an enrollee for more than the cost-sharing amount.
Under the bill, a provider or facility that is entitled to a payment for an emergency medical service or other item or service may initiate open negotiations with the defined network plan, preferred provider plan, or self-insured governmental health plan to determine the amount of payment. If the open negotiation period terminates without determination of the payment amount, the provider, facility, or plan may initiate the independent dispute resolution process as specified by the commissioner of insurance. If an enrollee of a plan is a continuing care patient, as defined in the bill, and is obtaining services from a participating provider or facility, and the contract is terminated because of a change in the terms of the participation of the provider or facility in the plan or the contract is terminated, resulting in a loss of benefits under the plan, the plan must notify the enrollee of the enrollee’s right to elect to continue transitional care, provide the enrollee an opportunity to notify the plan of the need for transitional care, and allow the enrollee to continue to have the benefits provided under the plan under the same terms and conditions as would have applied without the termination until either 90 days after the termination notice date or the date on which the enrollee is no longer a continuing care patient, whichever is earlier.
This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
AB1218,1
1
Section
1
.
609.04 of the statutes is created to read:
AB1218,2,3
2
609.04
Preventing surprise medical bills; emergency medical
3
services.
(1)
Definitions.
In this section:
AB1218,2,4
4
(a) “Emergency medical condition” means all of the following:
AB1218,2,8
5
1. A medical condition, including a mental health condition or substance use
6
disorder condition, manifesting itself by acute symptoms of sufficient severity,
7
including severe pain, such that the absence of immediate medical attention could
8
reasonably be expected to result in any of the following:
AB1218,2,10
9
a. Placing the health of the individual or, with respect to a pregnant woman,
10
the health of the woman or her unborn child in serious jeopardy.
AB1218,2,11
11
b. Serious impairment of bodily function.
AB1218,2,12
12
c. Serious dysfunction of any bodily organ or part.
AB1218,2,16
13
2. With respect to a pregnant woman who is having contractions, a medical
14
condition for which there is inadequate time to safely transfer the pregnant woman
15
to another hospital before delivery or for which the transfer may pose a threat to the
16
health or safety of the pregnant woman or the unborn child.
AB1218,2,19
17
(b) “Emergency medical services,” with respect to an emergency medical
18
condition, has the meaning given for “emergency services” in
42 USC 300gg-111
(a)
19
(3) (C).
AB1218,3,2
1
(c) “Independent freestanding emergency department” has the meaning given
2
in
42 USC 300gg-11
1 (a) (3) (D).
AB1218,3,4
3
(d) “Out-of-network rate” has the meaning given by the commissioner by rule
4
or, in the absence of such rule, the meaning given in
42 USC 300gg-111
(a) (3) (K).
AB1218,3,8
5
(e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
6
preferred provider plan, as defined in s. 609.01 (4), that has a network of
7
participating providers and imposes on enrollees different requirements for using
8
providers that are not participating providers.
AB1218,3,10
9
(f) “Recognized amount” has the meaning given by the commissioner by rule
10
or, in the absence of such rule, the meaning given in
42 USC 300gg-111
(a) (3) (H).
AB1218,3,14
11
(g) “Self-insured governmental plan” means a self-insured health plan of the
12
state or a county, city, village, town, or school district that has a network of
13
participating providers and imposes on enrollees in the self-insured health plan
14
different requirements for using providers that are not participating providers.
AB1218,3,17
15
(h) “Terminated” means the expiration or nonrenewal of a contract.
16
“Terminated” does not include a termination of a contract for failure to meet
17
applicable quality standards or for fraud.
AB1218,3,22
18
(2)
Emergency medical services.
A defined network plan, preferred
19
provider plan, or self-insured governmental plan that covers any benefits or
20
services provided in an emergency department of a hospital or emergency medical
21
services provided in an independent freestanding emergency department shall
22
cover emergency medical services in accordance with all of the following:
AB1218,3,23
23
(a) The plan may not require a prior authorization determination.
AB1218,4,3
1
(b) The plan may not deny coverage on the basis of whether or not the health
2
care provider providing the services is a participating provider or participating
3
facility.
AB1218,4,6
4
(c) If the emergency medical services are provided to an enrollee by a provider
5
or in a facility that is not a participating provider or participating facility, the plan
6
complies with all of the following:
AB1218,4,10
7
1. The emergency medical services are covered without imposing on an
8
enrollee a requirement for prior authorization or any coverage limitation that is
9
more restrictive than requirements or limitations that apply to emergency medical
10
services provided by participating providers or in participating facilities.
AB1218,4,14
11
2. Any cost-sharing requirement imposed on an enrollee for the emergency
12
medical services is no greater than the requirements that would apply if the
13
emergency medical services were provided by a participating provider or in a
14
participating facility.
AB1218,4,19
15
3. Any cost-sharing amount imposed on an enrollee for the emergency medical
16
services is calculated as if the total amount that would have been charged for the
17
emergency medical services if provided by a participating provider or in a
18
participating facility is equal to the recognized amount for such services, plan or
19
coverage, and year.
AB1218,4,20
20
4. The plan does all of the following:
AB1218,4,23
21
a. No later than 30 days after the participating provider or participating
22
facility transmits to the plan the bill for emergency medical services, sends to the
23
provider or facility an initial payment or a notice of denial of payment.
AB1218,5,3
1
b. Pays to the participating provider or participating facility a total amount
2
that, incorporating any initial payment under subd. 4. a., is equal to the amount by
3
which the out-of-network rate exceeds the cost-sharing amount.
AB1218,5,8
4
5. The plan counts any cost-sharing payment made by the enrollee for the
5
emergency medical services toward any in-network deductible or out-of-pocket
6
maximum applied by the plan in the same manner as if the cost-sharing payment
7
was made for emergency medical services provided by a participating provider or in
8
a participating facility.
AB1218,5,14
9
(3)
Nonparticipating provider in participating facility.
For items or
10
services other than emergency medical services that are provided to an enrollee of
11
a defined network plan, preferred provider plan, or self-insured governmental plan
12
by a provider who is not a participating provider but who is providing services at a
13
participating facility, the plan shall provide coverage for the item or service in
14
accordance with all of the following:
AB1218,5,17
15
(a) The plan may not impose on an enrollee a cost-sharing requirement for the
16
item or service that is greater than the cost-sharing requirement that would have
17
been imposed if the item or service was provided by a participating provider.
AB1218,5,21
18
(b) Any cost-sharing amount imposed on an enrollee for the item or service is
19
calculated as if the total amount that would have been charged for the item or
20
service if provided by a participating provider is equal to the recognized amount for
21
such item or service, plan or coverage, and year.
AB1218,5,23
22
(c) No later than 30 days after the provider transmits the bill for services, the
23
plan shall send to the provider an initial payment or a notice of denial of payment.
AB1218,6,4
1
(d) The plan shall make a total payment directly to the provider who provided
2
the item or service to the enrollee that, added to any initial payment described
3
under par. (c), is equal to the amount by which the out-of-network rate for the item
4
or service exceeds the cost-sharing amount.
AB1218,6,8
5
(e) The plan counts any cost-sharing payment made by the enrollee for the
6
item or service toward any in-network deductible or out-of-pocket maximum
7
applied by the plan in the same manner as if the cost-sharing payment was made
8
for the item or service when provided by a participating provider.
AB1218,6,14
9
(4)
Charging for services by nonparticipating provider; notice and
10
consent.
(a) Except as provided in par. (c), a provider of an item or service who is
11
entitled to payment under sub. (3) may not bill or hold liable an enrollee for any
12
amount for the item or service that is more than the cost-sharing amount
13
calculated under sub. (3) (b) for the item or service unless the nonparticipating
14
provider provides notice and obtains consent in accordance with all of the following:
AB1218,6,17
15
1. The notice states that the provider is not a participating provider in the
16
enrollee’s defined network plan, preferred provider plan, or self-insured
17
governmental plan.
AB1218,6,21
18
2. The notice provides a good faith estimate of the amount that the
19
nonparticipating provider may charge the enrollee for the item or service involved,
20
including notification that the estimate does not constitute a contract with respect
21
to the charges estimated for the item or service.
AB1218,7,2
22
3. The notice includes a list of the participating providers at the participating
1
facility who would be able to provide the item or service and notification that the
2
enrollee may be referred to one of those participating providers.
AB1218,7,5
3
4. The notice includes information about whether or not prior authorization or
4
other care management limitations may be required before receiving an item or
5
service at the participating facility.
AB1218,7,7
6
5. The notice clearly states that consent is optional and that the patient may
7
elect to seek care from an in-network provider.
AB1218,7,8
8
6. The notice is worded in plain language.
AB1218,7,10
9
7. The notice is available in languages other than English. The commissioner
10
shall identify languages for which the notice should be available.
AB1218,7,15
11
8. The enrollee provides consent to the nonparticipating provider to be treated
12
by the nonparticipating provider, and the consent acknowledges that the enrollee
13
has been informed that the charge paid by the enrollee may not meet a limitation
14
that the enrollee’s defined network plan, preferred provider plan, or self-insured
15
governmental plan places on cost sharing, such as an in-network deductible.
AB1218,7,17
16
9. A signed copy of the consent described under subd. 8. is provided to the
17
enrollee.
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