2011 WISCONSIN ACT
189
An Act
to repeal
49.475 (1) (ag) and 49.475 (1) (am);
to amend
49.475 (title), 49.475 (1) (c) (intro.), 49.475 (1) (c) 2., 49.475 (1) (d), 49.475 (1) (f) (intro.), 49.475 (1) (f) 2. and 49.475 (1) (f) 3.; and
to create
49.475 (1) (f) 5., 49.475 (1) (f) 6., 49.475 (1) (f) 7. and 49.475 (2m) of the statutes;
relating to:
the provision of information regarding health care benefits provided to certain assistance program recipients.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
Section
1
.
49.475 (title) of the statutes is amended to read:
49.475
(title)
Information about
medical
assistance
program
beneficiaries.
Section
2
.
49.475 (1) (ag) of the statutes is repealed.
Section
3
.
49.475 (1) (am) of the statutes is repealed.
Section
4
.
49.475 (1) (c) (intro.) of the statutes is amended to read:
49.475
(1)
(c) (intro.) "Pharmacy benefits management" means the
procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the
administration or management of prescription drug benefits provided by
a covered entity for the benefit of covered individuals; or
an insurer or other 3rd party, including the performance of
any of the following services
provided in the administration of pharmacy benefits
:
Section
5
.
49.475 (1) (c) 2. of the statutes is amended to read:
49.475
(1)
(c) 2. Claims processing, retail network management,
and
or
payment of claims to pharmacies for prescription drugs dispensed to
covered
individuals.
Section
6
.
49.475 (1) (d) of the statutes is amended to read:
49.475
(1)
(d) "Pharmacy benefits manager" means
a person
an entity
that performs pharmacy benefits management
functions
.
Section
7
.
49.475 (1) (f) (intro.) of the statutes is amended to read:
49.475
(1)
(f) (intro.) "Third party" means an entity that by statute, rule,
or
contract
, or agreement
is responsible for payment of a claim for a health care item or service
. "Third party" includes all
, including any
of the following:
Section
8
.
49.475 (1) (f) 2. of the statutes is amended to read:
49.475
(1)
(f) 2. An employee benefit plan
described
, as defined
in 29 USC
1003 (a) that is not exempt under 29 USC 1003 (b) and is not a multiple employer welfare arrangement
1002 (3)
.
Section
9
.
49.475 (1) (f) 3. of the statutes is amended to read:
49.475
(1)
(f) 3. A service benefit plan, as
specified in 42 USC 1396a (25) (I)
defined in
5 USC 8903
(1)
.
Section
10
.
49.475 (1) (f) 5. of the statutes is created to read:
49.475
(1)
(f) 5. A group health plan, as defined in
29 USC 1191b
(a) (1), including a self-insured plan.
Section
11
.
49.475 (1) (f) 6. of the statutes is created to read:
49.475
(1)
(f) 6. The issuer of a disability insurance policy.
Section
12
.
49.475 (1) (f) 7. of the statutes is created to read:
49.475
(1)
(f) 7. An entity that administers benefits on behalf of another risk-bearing 3rd party, including a 3rd-party administrator, a fiscal intermediary, or a managed care contractor.
Section
13m
.
49.475 (2m) of the statutes is created to read:
49.475
(2m)
Limits on information to be provided.
(a) The information that the department may request under this section is limited to the information specified in sub. (2) (a) and does not include an employer's name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.
(b) If information under sub. (2) (a) may be available from more than one source that includes an employer operating a self-insured plan, the department shall seek the information first from a 3rd-party administrator or other entity identified in sub. (1) (f) 7. or pharmacy benefits manager before seeking the information from the employer.
(c) Information obtained under this section may be used only for the purposes specified in this section and in federal law on 3rd-party liability in Medical Assistance programs.
Section
14m
.
Effective date.
(1)
This act takes effect on the first day of the 7th month beginning after publication.
