WHAT THIS BILL REGULATES · 1 REQUIREMENT TYPE
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
609.825 Human review of prior authorization for medical necessity or experimental status. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.852.
Section 609.825 is a short cross-reference provision that extends the substantive prohibition in § 632.852 to three categories of managed care entities: limited service health organizations, preferred provider plans, and defined network plans. It creates no independent obligation but ensures these plan types are subject to the same AI prior-authorization prohibition.
1 632.852 Human review of prior authorization for medical necessity or experimental status. A disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c), may not use artificial intelligence to deny a prior authorization for medical necessity or experimental status. An appropriate licensed health care provider who is an individual shall review a prior authorization that involves medical necessity or experimental status before the disability insurance policy or self-insured health plan may deny the prior authorization.
Section 632.852 is the bill's core operative provision. It imposes two linked obligations on disability insurance policies and self-insured health plans. First, these entities may not use artificial intelligence to deny a prior authorization for medical necessity or experimental status — a categorical prohibition on AI-only denials in this context. Second, before any such denial may issue, an appropriate licensed health care provider who is an individual must review the prior authorization. Together, these requirements ensure that a human clinical professional stands between an AI recommendation and a coverage denial based on medical necessity or experimental status.
The bill does not define artificial intelligence, leaving that term to its ordinary meaning or future regulatory guidance. Nor does it specify who qualifies as an appropriate licensed health care provider, though the term implies clinical competence relevant to the subject matter of the authorization request.
(1) For policies and plans containing provisions inconsistent with s. 632.852, the treatment of s. 632.852 first applies to policy or plan years beginning on the effective date of this subsection, except as provided in sub. (2).
(2) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with s. 632.852, the treatment of s. 632.872 first applies to policy or plan years beginning on the effective date of this subsection or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.
Section 3 governs the phased applicability of the new § 632.852 prohibition. For most policies and plans, the prohibition applies beginning with policy or plan years starting on the effective date. For plans governed by a collective bargaining agreement with inconsistent provisions, applicability is delayed until the later of the effective date or the date the collective bargaining agreement is newly established, extended, modified, or renewed.
(1) This act takes effect on the first day of the 4th month beginning after publication.
The act takes effect on the first day of the fourth month beginning after publication, a standard Wisconsin effective-date formula that delays applicability to allow affected entities to come into compliance.