SB 418

This bill requires a health care provider to disclose to a consumer the provider's

median billed charge for a health care service, diagnostic test, or procedure, upon

request. The bill also requires a health care provider to disclose specified charge

information for the 25 presenting conditions for which the provider most frequently

provides services, as identified by the Department of Health Services (DHS). The bill

requires DHS to consult with the Wisconsin Collaborative for Healthcare Quality,

and to use Medical Assistance claims data, in identifying the presenting conditions

for each health care provider. Under the bill, a health care provider must create a

document that lists the following charge information for diagnosing and treating

each of the 25 presenting conditions identified by DHS for the provider: 1) the

provider's median billed charges; 2) the reimbursement amount under Medical

Assistance, if the health care provider participates in the Medical Assistance

Program; 3) the reimbursement amount under Medicare, if the provider participates

in Medicare; and 4) the average allowable payment from private, third-party payers.

A health care provider must update the document annually.

Under the bill, these provisions relating to disclosing charge information apply

to health care facilities such as a hospital, ambulatory surgical center, or nursing

home, and to associations of health care provides that include four or more

practitioners.

Under the bill, a self-insured health plan of the state or a county, city, village,

town, or school district, or an insurer that provides coverage under a health

insurance policy, including defined network plans and sickness care plans operated

by cooperative associations, must provide to an insured under the health insurance

policy or an enrollee under the self-insured health plan a good faith estimate of the

median reimbursement that the insurer or self-insured health plan would expect to

pay for a specified health care service in the geographic region in which the service

will be provided. In addition, the insurer or self-insured health plan must provide

to an insured or enrollee a good faith estimate of the insured's or enrollee's total

out-of-pocket cost for the specified service. The information must be provided only

if the insured or enrollee requests it, and it must be provided at no charge to the

insured or enrollee. Before providing any of the information, the insurer or

self-insured health plan may require the insured or enrollee to provide the name of

the provider providing the service, the facility at which the service will be provided,

the date the service will be provided, the provider's estimate of the charges, and the

Current Procedural Terminology code or Current Dental Terminology code for the

service. In addition, the bill provides that any good faith estimate provided is not a

legally binding estimate.

The bill also requires health care providers to display prominently statements

informing health care consumers of the consumers' right to receive charge

information from the health care providers and from their insurers.