AB1140: Bill Text

AB1140,9,18 g. Two designated by the governor to represent consumers.

AB1140,9,20 3. That the term of a director shall be 4 years, except that the term of an initial director shall be one year.

AB1140,9,21 4. The names and addresses of the initial directors.

AB1140,9,24 5. That 7 votes shall be necessary for adoption of any decision of the board, except for those designated categories of decisions, if any, that the board agrees to adopt by a simple majority of the votes.

AB1140,10,2 (c) In consultation with the persons charged with designating the directors under par. (b) 2. a. to g., designate the initial directors.

AB1140,10,3 (d) Draft bylaws for adoption by the board.

AB1140,10,5 (2) Duties. As a condition for the release of funds under s. 20.855 (8m) (r), the corporation shall do all of the following:

AB1140,10,9 (a) Establish, fund, and manage health insurance purchasing accounts in the manner provided in this chapter; assist eligible residents in using their accounts to purchase health care coverage; and perform all other functions required of the corporation under this chapter.

AB1140,10,11 (b) Establish an independent and binding appeals process for resolving disputes over eligibility and other determinations made by the corporation.

AB1140,10,14 (c) Keep its records open at all times to inspection and examination by the governor, the secretary of administration, any committee of either or both houses of the legislature, the legislative fiscal bureau, and the legislative audit bureau.

AB1140,10,16 (d) Keep its meetings open to the public to the extent required of governmental bodies under subch. V of ch. 19.

AB1140,10,18 (e) Cooperate with the legislative audit bureau in the performance of the audits under sub. (4).

AB1140,10,21 (f) Submit on each October 1 an annual report to the legislature under s. 13.172 (2) and to the governor regarding its activities and including any recommendations of the health care advisory committee under s. 260.40 (1) (d).

AB1140,10,25 (3) Contracts and hiring. (a) The corporation may contract with other organizations, entities, or individuals for the performance of any of its functions. With respect to contracts under this subsection, the corporation shall do all of the following:

AB1140,11,4 1. Use generally accepted procedures, which shall be in writing and open to public inspection, for soliciting bids or proposals and for awarding contracts to the lowest-bidding, qualified person or to the most qualified person submitting a proposal.

AB1140,11,7 2. Make open to public inspection all of its requests for bids or proposals, all of its analyses of bids or proposals received, and all of its final decisions on bids or proposals received.

AB1140,11,9 (b) The corporation shall use generally accepted hiring practices, which shall be in writing and open to public inspection, for hiring any staff.

AB1140,11,17 (4) Audits. At least once every 2 years, the legislative audit bureau shall conduct a financial audit of the corporation and a performance evaluation audit of the health insurance purchasing arrangement under this chapter that includes an audit of the corporation's policies and management practices. The legislative audit bureau shall distribute a copy of each audit report under this subsection to the legislature under s. 13.172 (2) and to the governor. The corporation shall reimburse the legislative audit bureau for the cost of the audits and reports required under this subsection.

AB1140,12,5 260.10 Health insurance purchasing accounts. (1) Establishment and funding. (a) Beginning in January 2008, the corporation shall establish a private health insurance purchasing account for each eligible resident, except for an eligible resident who notifies the corporation that, for religious reasons, he or she does not wish to have an account. Beginning in 2009, the corporation annually shall credit to each account a dollar amount that is the full premium, as determined by the corporation under s. 260.15 (2) (b), of any of the Tier 1 health care plans offered in the county in which the eligible resident resides and that has been actuarially adjusted for the eligible resident based on age, sex, and other appropriate risk factors determined by the board. Subject to sub. (2) and s. 260.20 (3), the corporation shall pay the amount credited under this paragraph to the health care plan selected by the eligible resident, or to which the eligible resident has been assigned, under s. 260.15 (3).

AB1140,12,11 (b) 1. The health insurance purchasing account of an eligible resident who is at least 18 years of age shall also include a health savings account, as described in 26 USC 223. For an eligible resident who is under 18 years of age when his or her health insurance purchasing account is established, his or her health insurance purchasing account shall include a health savings account beginning in the year in which the eligible resident is 18 years of age on January 1.

AB1140,12,17 2. Beginning in 2009, the corporation annually shall deposit an amount into each health savings account. Subject to s. 260.20 (5), the amount deposited in 2009 shall be $500 and the amount deposited in each year thereafter shall be adjusted to reflect the annual percentage change in the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, for the 12-month period ending on December 31 of the preceding year.

AB1140,12,20 3. If the corporation estimates that revenues will exceed costs in a year, the corporation may deposit into each health savings account an amount in addition to the amount deposited under subd. 2.

AB1140,12,25 4. In addition to amounts deposited under subds. 2. and 3., the corporation may deposit into the health savings account of an eligible resident who successfully follows a healthy lifestyle protocol certified by the corporation under s. 260.40 (2) (a), an amount determined by the corporation to be equal to the average reduction in health care costs per eligible resident who adopts a healthy lifestyle protocol.

AB1140,13,3 5. Notwithstanding subds. 2., 3., and 4., the total amount deposited in an eligible resident's health savings account may not exceed the maximum amount allowed under federal law.

AB1140,13,9 (2) Additional payment for disproportionate risk. The corporation may retain a percentage of the amounts credited under sub. (1) (a) to pay to health care plans that have incurred disproportionate risk not fully compensated for by the actuarial adjustment in the amount credited to each account under sub. (1) (a). Any payment to a health care plan under this subsection shall reflect the disproportionate risk incurred by the health care plan.

AB1140,13,14 260.15 Health care plans. (1) Participation of insurers. (a) Subject to par. (c), the corporation shall solicit bids from, and enter into contracts with, insurers for offering coverage to eligible residents. Any insurer that is authorized to do business in this state in one or more lines of insurance that includes health insurance is eligible to submit a bid.

AB1140,13,18 (b) In determining which insurers qualify to offer coverage, the corporation shall use financial, coverage, and disclosure standards that are comparable to those that the department of employee trust funds has used in qualifying insurers for offering coverage under the state employee health plan under s. 40.51 (6).

AB1140,13,20 (c) The corporation shall ensure that in each county at least 2 health care plans are offered by at least 2 different insurers.

AB1140,14,3 (2) Tier assignment and premium determination. (a) The corporation shall rank the health care plans offered in each county and assign each health care plan to one of 3 tiers, on a countywide basis, based on the health care plan's risk-adjusted cost and quality. The corporation shall assign to "Tier 1" health care plans that it determines provide high quality care at a low risk-adjusted cost, assign to "Tier 2" health care plans that it determines provide care at a higher risk-adjusted cost, and assign to "Tier 3" health care plans that it determines provide care at the highest risk-adjusted cost.

AB1140,14,9 (b) The corporation shall determine the monthly premium amount for each health care plan, including the out-of-pocket monthly premium amounts that eligible residents must pay to enroll in Tier 2 health care plans and Tier 3 health care plans. The out-of-pocket monthly premium amounts shall be based on the actual differences in risk-adjusted cost between Tier 1 and Tier 2 health care plans, and between Tier 1 and Tier 3 health care plans.

AB1140,14,18 (3) Plan selection. Beginning in 2008, the corporation shall offer an annual open enrollment period during which each eligible resident may select a health care plan from among those offered. Coverage under the health care plan that an eligible resident selects during an annual open enrollment period shall be effective on the following January 1. An eligible resident who does not select a health care plan will be randomly assigned to a Tier 1 health care plan. An eligible resident who selects a Tier 2 or Tier 3 health care plan but who fails, as defined by the corporation, to pay the out-of-pocket monthly premium amount will be randomly assigned to a Tier 1 health care plan.

AB1140,14,22 260.20 Benefits. (1) Generally. Coverage under this chapter shall begin on January 1, 2009, and shall include medical and hospital care coverage and related health care services as determined by the corporation, prescription drug coverage, and limited dental care coverage, as provided in sub. (4).

AB1140,14,25 (2) Benefits without certain cost sharing. Deductibles, coinsurance, and copayments shall not apply to coverage of any of the following health care services, as defined by the corporation:

AB1140,15,1 (a) Emergency care.

AB1140,15,2 (b) Prenatal care for pregnant women.

AB1140,15,3 (c) Well-baby care.

AB1140,15,4 (d) Annual medical examinations for children up to 18 years of age.

AB1140,15,5 (e) Medically indicated immunizations for children up to 18 years of age.

AB1140,15,6 (f) Annual gynecological examinations for older girls and women.

AB1140,15,7 (g) Medically indicated Papanicolaou tests and mammograms.

AB1140,15,8 (h) Annual medical examinations for older men.

AB1140,15,9 (i) Medically indicated colonoscopies.

AB1140,15,10 (j) The limited dental care specified in sub. (4).

AB1140,15,13 (k) Other preventive services or procedures, as determined by the corporation, for which there is scientific evidence that exemption from cost sharing is likely to reduce health care costs or avoid health risks.

AB1140,15,17 (3) Pharmacy benefit. (a) Except as provided in par. (b), the corporation shall assume the risk for, and pay for, prescription drugs provided to eligible residents. For this purpose, the corporation shall retain the portion of the amount credited under s. 260.10 (1) (a) that is actuarially allocated for prescription drug coverage.

AB1140,15,22 (b) If the corporation determines that the method of providing prescription drug coverage under par. (a) is not cost-effective, the corporation may require the health care plans to provide prescription drug coverage to eligible residents and shall pay the portion of the amount credited under s. 260.10 (1) (a) that is actuarially allocated for prescription drug coverage to the eligible residents' health care plans.

AB1140,16,2 (4) Dental benefit. Every health care plan shall provide coverage of dental examinations and the application of varnishes and sealants, as determined by the corporation, for eligible residents who are at least 2 years of age but not more than 16 years of age.

AB1140,16,7 (5) Benefit and health savings account deposit reductions. (a) If the corporation determines, based on information and recommendations received from its actuaries, that the cash balance in the health insurance purchasing trust fund is likely to be insufficient for providing the health care benefits under subs. (1) to (4), the corporation shall inform the governor and the legislature of all of the following:

AB1140,16,8 1. That expenses will exceed revenues for one or more specified years.

AB1140,16,11 2. What increase in revenues would be required to maintain the current health savings account and benefit levels and bring revenues and expenses into balance for the year or years specified in subd. 1.

AB1140,16,15 3. Alternative reductions in the amount deposited into health savings accounts under s. 260.10 (1) (b) 2. or in the benefits under this section that would be appropriate to bring revenues and expenses into balance for the year or years specified in subd. 1.

AB1140,16,19 4. The revenue increase, health savings account deposit reduction, or benefit reductions, or the combination of increase and reductions, that the corporation recommends to bring revenues and expenses into balance for the year or years specified in subd. 1.

AB1140,16,24 5. The health savings account deposit reduction or benefit reductions that the corporation prefers to bring revenues and expenses into balance for the year or years specified in subd. 1. if legislation that increases revenues, reduces the health savings account deposit under s. 260.10 (1) (b) 2., or reduces benefits provided under this section is not enacted before the beginning of the first year specified in subd. 1.

AB1140,17,4 (b) If legislation to bring revenues and expenses into balance for the year or years specified in par. (a) 1. is not enacted before the beginning of the first year specified, the corporation shall implement the health savings account deposit reduction or benefit reductions specified in par. (a) 5.

AB1140,17,8 260.25 Cost sharing. (1) Premiums. (a) An eligible resident who selects or is assigned to coverage under a Tier 1 health care plan shall pay no premium in addition to the amount paid by the corporation under s. 260.10 (1) (a) to the eligible resident's health care plan.

AB1140,17,12 (b) An eligible resident who selects coverage under a Tier 2 or Tier 3 health care plan shall be required to pay to the selected Tier 2 or Tier 3 health care plan, as a condition of enrollment, the out-of-pocket monthly premium determined by the corporation under s. 260.15 (2) (b).

AB1140,17,14 (2) Deductibles. Except as provided in s. 260.20 (2) and subject to sub. (4), in a year, an eligible resident shall pay the following annual deductible amount:

AB1140,17,16 (a) For an eligible resident who is 18 years of age or older on January 1 of that year, $1,200.

AB1140,17,18 (b) For an eligible resident who is under 18 years of age on January 1 of that year, $100.

AB1140,17,21 (3) Coinsurance and copayments. Except as provided in s. 260.20 (2) and subject to sub. (4), in a year, after the deductible under sub. (2) has been satisfied, an eligible resident shall pay all of the following:

AB1140,17,24 (a) Coinsurance that is equal to at least 10 percent but not more than 20 percent of medical, hospital, related health care services, and prescription drug costs, as determined by the corporation.

AB1140,18,5 (b) For each prescription of a brand-name drug that is on the preferred list determined by the corporation under s. 260.20 (3) (a) or by the eligible resident's health care plan under s. 260.20 (3) (b), in addition to the coinsurance required under par. (a), either coinsurance of at least 10 percent but not more than 20 percent or a copayment, as determined by the corporation.

AB1140,18,10 (c) For each prescription of a brand-name drug that is not on the preferred list determined by the corporation under s. 260.20 (3) (a) or by the eligible resident's health care plan under s. 260.20 (3) (b), in addition to the coinsurance required under par. (a), either coinsurance of at least 20 percent but not more than 40 percent or a copayment, as determined by the corporation.

AB1140,18,13 (4) Maximum amounts. (a) Subject to par. (c), an eligible resident under sub. (2) (a) may not be required to pay more than $2,000 per year in total cost sharing under subs. (2) and (3).

AB1140,18,15 (b) Subject to par. (c), an eligible resident under sub. (2) (b) may not be required to pay more than $500 per year in total cost sharing under subs. (2) and (3).

AB1140,18,17 (c) A family consisting of 2 or more eligible residents may not be required to pay more than $3,000 per year in total cost sharing under subs. (2) and (3).

AB1140,18,23 (5) Adjustments. (a) Notwithstanding subs. (2) to (4), the corporation shall reduce the deductible, coinsurance, copayment, or maximum cost-sharing amounts, or any combination of those amounts, for low-income eligible residents, as determined by the corporation, to ensure that the cost sharing required does not deter low-income eligible residents from seeking and using appropriate health care services.

AB1140,19,3 (b) Notwithstanding subs. (2) to (4), beginning in 2010, the corporation annually shall adjust the deductible and maximum cost-sharing amounts to reflect the annual percentage change in the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, for the 12-month period ending on December 31 of the preceding year.

AB1140,19,9 260.30 Preexisting condition exclusion. (1) To whom applicable. Subject to sub. (2), a health care plan may not provide coverage for any preexisting condition, as defined by the corporation, of an eligible resident who, at any time during the 18-month period before becoming an eligible resident, resided outside of Wisconsin and did not have health insurance coverage that was substantially similar to the coverage provided under this chapter, as determined by the corporation.

AB1140,19,12 (2) Length of exclusion. A preexisting condition exclusion under sub. (1) may not extend beyond the date on which the eligible resident has been continuously covered under this chapter for a total of 18 months.

AB1140,19,21 260.40 Health care advisory committee; health care policies. (1) Establishment of committee. (a) The corporation shall establish a health care advisory committee to advise it on all matters related to promoting healthier lifestyles; promoting health care quality; increasing the transparency of health care cost and quality information; preventive care; disease management; the appropriate use of primary care, medical specialists, prescription drugs, and hospital emergency rooms; confidentiality of medical information; the appropriate use of technology; benefit design; the availability of physicians, hospitals, and other providers; and reducing health care costs.

AB1140,19,22 (b) The committee shall consist of the following:

AB1140,19,23 1. Three members designated by the Wisconsin Medical Society.

AB1140,19,24 2. Three members designated by the Wisconsin Hospital Association.

AB1140,20,2 3. One member designated by the dean of the University of Wisconsin School of Medicine and Public Health.

AB1140,20,4 4. One member designated by the president of the Medical College of Wisconsin.

AB1140,20,5 5. One member designated by the Wisconsin Nurses Association.

AB1140,20,7 6. One member designated by the Wisconsin Federation of Nurses and Health Professionals.

AB1140,20,8 7. One member designated by the Wisconsin Chiropractic Association.

AB1140,20,9 8. One member designated by the Wisconsin Dental Association.

AB1140,20,16 (c) The committee members shall elect a chairperson from among the members. The chairperson, or his or her designee, shall attend every meeting of the board to communicate to the corporation the advice and recommendations of the committee. The chairperson, or his or her designee, shall communicate to the committee any questions on which the corporation is seeking the committee's advice or recommendations. The corporation shall vote on each recommendation submitted to it by the committee as to whether the recommendation should be implemented.

AB1140,20,21 (d) Annually, on or before September 1, the committee shall submit to the corporation a summary of all of its recommendations during the previous 12 months for improving the health insurance purchasing arrangement under this chapter. The corporation shall include those recommendations and the votes taken by the corporation on them in its annual report under s. 260.05 (2) (f).

AB1140,20,23 (2) Adoption of health care policies. The corporation shall do all of the following:

AB1140,21,3 (a) In consultation with the health care advisory committee and experts on creating effective incentives for individuals and employers relating to healthier lifestyles, adopt evidence-based policies that create incentives for eligible residents to adopt healthier lifestyles and for employers to institute work-based programs that have been shown to improve the health status of employees and their families.

AB1140,21,12 (b) In consultation with the health care advisory committee and experts on increasing the transparency of health care cost and quality information, and in collaboration with the health care advisory committee and health care plans and health care providers, adopt policies that provide eligible residents with current, comprehensive, easily accessible, and easily understandable information about the cost and quality of the care provided by Wisconsin health care providers and by any physicians, clinics, or hospitals outside of Wisconsin that are included in a network of a health care plan offered under the health insurance purchasing arrangement under this chapter.

AB1140,21,16 (c) In consultation with the health care advisory committee, the Wisconsin Health Information Organization, the Wisconsin Collaborative for Health Care Quality, and other medical and nonmedical experts on health care quality, promote evidence-based improvements in the quality of health care delivery in Wisconsin.

AB1140,21,24 260.60 Including certain residents who are eligible for Medical Assistance. (1) Plan. The corporation and the department of health and family services shall jointly develop a plan for providing health care coverage under the health insurance purchasing arrangement established under this chapter to individuals who satisfy the criteria under s. 260.01 (3) (a) 1. to 4. and who are eligible for Medical Assistance under subch. IV of ch. 49 in the low-income families category, as determined under 2005 Wisconsin Act .... (this act), section 14 (1 ) (b), or for health care coverage under the Badger Care health care program under s. 49.665.

AB1140,22,5 (2) Waiver request. The department of health and family services shall, no later than July 1, 2010, submit to the legislature under s. 13.172 (2) the plan developed under sub. (1), together with its recommendations concerning the desirability of requesting waivers from the secretary of the federal department of health and human services for all of the following purposes:

AB1140,22,6 (a) To implement the plan developed under sub. (1).