The 2025-2026 legislative session is now in full swing commencing in earnest with the Governor’s bi-annual budget address. The Governor has deemed this the “year of the kid” as his address focused on education, clean drinking water and a tax cut plan. Governor Evers also honed in on a message that went after prescription drug costs and health insurers.  Republican legislators largely dismissed the Governor’s plans and have stated they will once again craft a budget of their own focused on using the Wisconsin’s $4 billion surplus to provide an extensive tax cut.

Highlights from the Governor’s provisions relating to health insurance:

• Require OCI to establish a framework for auditing high rates of health insurance claims denials.

• OCI audit of insurers with claims denial rates above a certain percentage, determined by OCI, and require corrective action plans based on the audit findings.

• Allow OCI to enforce corrective action plans through fines, forfeiture or other mechanisms.

• Prior Authorization Exemption Requirements (Gold Carding)

• Require OCI to develop parameters for when services are exempt from requiring prior authorization; providers who receive prior authorization approvals above a certain rate would be exempt from requiring prior authorization for services provided or 
  recommended by them.

• Prior Authorization Transparency

• Require insurers to provide consumers with a list of treatments and services covered by health plans offered by the health insurer which require prior authorization.

• Create a Public Intervenor Office within OCI to provide information and assistance to consumers in receiving better claim outcomes. Consumers whose health insurance claims are denied would be assisted with appeals and other legal actions to pursue coverage for health care services.

While most of these provisions will get removed by the legislature from the state budget, some of them, like the prior authorization requirements, will likely be proposed in bill form by a bi-partisan coalition. WISCA will follow those developments closely and will voice support for provisions that improve ASC’s ability to serve their patients.

- Andy Engel, Hamilton Consulting