SB 373

Generally, this bill requires and prohibits certain actions related to prior authorization of physical therapy, occupational therapy, speech therapy, chiropractic services, and other health care services by certain health plans. Under the bill, health plans are prohibited from requiring prior authorization for the first 12 physical therapy, occupational therapy, speech therapy, or chiropractic visits with no duration of care limitation or for any physical therapy, occupational therapy, or chiropractic care for the nonpharmacologic management of pain provided to individuals with chronic pain for the first 90 days of treatment, not to exceed a frequency of twice per week per service. Under the bill, “chronic pain” is defined to mean persistent or recurring pain lasting three months or longer. Further, the bill provides that every health plan, when requested to authorize coverage following completion of the initial 12 visits or subsequent to a request for reauthorization of coverage, shall issue a decision on reauthorization within three business days of receiving the request. If a health plan does not issue a decision on reauthorization within three business days of receiving the request, prior authorization is assumed to be granted for the service.

The bill requires health plans that provide coverage of physical therapy services, occupational therapy services, speech therapy services, or chiropractic services to reference the applicable policy and include an explanation to the service provider and to the covered individual for any denial of coverage for or reduction in covered services and to impose copayment and coinsurance amounts on covered individuals for provided services that are equivalent to copayment and coinsurance amounts imposed for primary care services under the plan whenever copayment or coinsurance is required.

The bill also requires every utilization review organization and utilization management organization that is providing review or management on behalf of a health plan to provide to any licensed health care provider, upon request, all medical evidence-based policy information that accompanies the algorithms that are used to manage coverage and to operate and staff peer review activities with Wisconsin-licensed health care providers holding credentials for the type of service that is the subject of the review. The bill prohibits utilization review organizations and utilization management organizations from using claims data as evidence of outcomes for purposes of developing an algorithm to manage coverage or an approval policy for coverage. Health plans to which the above requirements and prohibitions apply are private health benefit plans and self-insured governmental health plans.

Additionally, the bill prohibits health care plans and self-insured governmental health plans from requiring prior authorization for coverage of any covered service that is incidental to a covered surgical service and determined by the covered person’s physician or other health care provider to be medically necessary and of any covered urgent health care service as defined in the bill. Current law prohibits health care plans and self-insured governmental health plans from requiring prior authorization for coverage of emergency medical services.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.