The provision of information regarding health care benefits provided to certain assistance program recipients

What it does

Summary by the Legislative Reference Bureau, the Legislature's nonpartisan drafting office. It's their wording, not ours.

Under current law, as a condition of doing business in this state, certain payers of health care benefits (called third parties) must provide to the Department of Health Services (DHS) information from their records to enable DHS to ascertain whether an individual, or his or her spouse or dependent, who has been or is a recipient under an assistance program, has received or is receiving health care coverage or benefits from a third party. The assistance programs for which DHS seeks information about recipients are the Medical Assistance (MA) program, including the Badger Care health care program, Family Care, Senior Care, the Well-Woman Program, and the program that provides financial assistance for the cost of medical care to persons with chronic kidney disease, cystic fibrosis, and hemophilia. The third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHS of a recipient's right to receive payment from the third party for a health care item or service for which payment under an assistance program has been made, as well as the right of DHS to recover any third-party payment made for which assignment had not been accepted, and may not deny a DHS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHS to enforce its rights is commenced less than 72 months after DHS submits the claim.

This bill makes modifications to the third parties that are required to provide information to DHS and from which DHS may recover payments for health care services provided to recipients. Under current law, a third party is defined as an insurer, an employee benefit plan, a service benefit plan, or a pharmacy benefits manager. A service benefit plan, which is a plan providing health care benefits to federal government employees, is defined by a reference to federal law. The bill corrects the federal law citation for the definition. An employee benefit plan is also defined by a reference to federal law. The bill changes the federal law citation so that government-provided health care plans, which are exempted under the current law definition, are included. The bill also changes the definition of a pharmacy benefits manager, which, under current law, includes a person that performs pharmacy benefits management functions with respect to prescription drug benefits that are provided by a nonprofit hospital, an employer, a labor union, or another organization.

Who's behind it

Pam Galloway, a Republican, is its author⁠.

11 more lawmakers signed on in support⁠.

What it would cost

State agencies filed a cost estimate. Each opens as a PDF from the Legislature.

• Fiscal Estimate From DHS

Versions and amendments

Every text the Legislature printed for this bill, including proposed changes. Each opens on the Legislature's site.

• Amendment SA1-SB487
• LC Amendment Memo