An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g) and 185.983 (1) (intro.); to create 609.815, 628.42 and 632.848 of the statutes; Relating to: prior authorization transparency, exemptions from prior authorization requirements, and granting rule-making authority. (FE)
AB1217 would regulate how health care plans use prior authorization for covered services and items. It requires plans to maintain and publicly post a complete list of services that require prior authorization, along with current requirements, restrictions, and related clinical review criteria in plain language on a publicly accessible website. Plans would also have to give contracted providers at least 60 days’ advance written notice before adding or changing a prior authorization requirement, and they could not implement the change until the website is updated.
The bill also sets standards for the clinical review criteria used in prior authorization decisions. Those criteria must be based on nationally recognized, generally accepted standards, developed under current standards of a national medical accreditation entity, evidence-based, flexible enough to allow justified deviations, and reviewed at least annually. In addition, a claim could not be denied for failing to obtain prior authorization if the requirement was not in effect when the service was provided, and plans could not deny claims by labeling supplies or services as incidental when the associated service was authorized or did not require authorization.
AB1217 further authorizes the insurance commissioner to adopt rules creating exemptions from prior authorization for providers who meet a specified approval-rate threshold during a defined evaluation period. The commissioner could determine which items or services are eligible for exemption, how providers qualify, and whether automatic evaluation procedures are used. The bill applies these requirements to a range of state-regulated health coverage arrangements, including state employee plans, local government self-insured plans, school district self-insured plans, and certain nonprofit cooperative health plans, and it also references self-insured and disability plans affected by collective bargaining agreements.
The bill’s impact on state law would be to add new transparency, notice, and standards requirements to Wisconsin’s insurance code and related statutes governing public and self-insured health plans. It would create new sections 628.42 and 632.848, expand compliance obligations for several categories of plans, and give the insurance commissioner new rule-making authority over prior authorization exemptions. The bill also notes that it may contain a health insurance mandate requiring a social and financial impact report.
The available context suggests generally favorable or at least supportive treatment, with no recorded committee opposition or votes in the provided materials. The bill had bipartisan-style sponsorship and a later addition of a Senate cosponsor, which may indicate interest in the proposal. The main points of potential contention are likely to be administrative burden, compliance costs, and the scope of commissioner rule-making authority versus the bill’s consumer- and provider-protection goals. Health plans and utilization review organizations may be concerned about operational requirements, while providers and patients are likely to support the transparency and exemption provisions.
AB1217 would amend multiple Wisconsin statutes governing state employee coverage, local government self-insured plans, school district self-insured plans, and nonprofit cooperative health plans, while creating new insurance-code provisions on prior authorization transparency and exemptions. It would require public posting of prior authorization lists and criteria, advance notice before changes, and new standards for clinical review criteria, and it would authorize the insurance commissioner to establish exemption rules for providers with high approval rates.
The limited available context indicates a generally positive or reform-oriented sentiment around the bill, with bipartisan sponsorship and no recorded votes or committee objections in the materials provided. The addition of a Senate cosponsor suggests the proposal may have had some cross-chamber support, though the absence of hearing transcripts makes it difficult to gauge the full level of enthusiasm or opposition.
The likely areas of contention are the bill’s compliance and administrative demands on health plans, the requirement to publicly disclose detailed prior authorization information, and the breadth of the commissioner’s new rule-making authority to create exemptions. Supporters would likely emphasize transparency, reduced delays in care, and fewer unnecessary prior authorization requests, while opponents may argue the bill could increase costs, reduce utilization management flexibility, and create implementation challenges for plans and contracted review organizations.