"Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, as defined in s. 600.03 (27)
, nonprofit hospital or medical service plans under ch. 613
, cooperative medical service plans under s. 185.981
, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. "Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. "Insurer" does not include a plan under ch. 613
which offers only dental care.
"Medicare" means coverage under part A, part B, and part D of Title XVIII of the federal social security act, 42 USC 1395
et seq., as amended.
"Plan" means the health care insurance plan established and administered under subchapter II of this chapter.
"Policy" means any document other than a group certificate used to prescribe in writing the terms of an insurance contract, including endorsements and riders and service contracts issued by motor clubs.
"Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care or treatment related to the condition before that date.
"Premium" means any consideration for an insurance policy, and includes assessments, membership fees or other required contributions or consideration, however designated.
"Resident" means a person who has been legally domiciled in this state for a period of at least 3 months or, with respect to an eligible individual, an individual who resides in this state. For purposes of this chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability that prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state.
"State" means the same as in s. 990.01 (40)
except that it also includes the Panama Canal Zone.
History: 1997 a. 27
; Stats. 1997 s. 149.10; 1999 a. 9
; 2001 a. 38
; 2003 a. 33
; 2005 a. 74
No cause of action of any nature may arise against, and no liability may be imposed upon, the authority, plan, or board; or any agent, employee, or director of any of them; or participating insurers; or the commissioner; or any of the commissioner's agents, employees, or representatives, for any act or omission by any of them in the performance of their powers and duties under this chapter, unless the person asserting liability proves that the act or omission constitutes willful misconduct.
History: 2005 a. 74
HEALTH INSURANCE RISK-SHARING
Administration of plan. 149.11(1)
The authority shall be responsible for the operation of the plan and, subject to ss. 149.43 (2)
, may enter into contracts for the plan's administration.
The authority shall pay the operating and administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:
Any other moneys received by the authority from time to time.
The authority controls the assets of the fund and shall select regulated financial institutions in this state that receive deposits in which to establish and maintain accounts for assets needed on a current basis. If practicable, the accounts shall earn interest.
Moneys in the fund may be expended only for the purposes specified in par. (a)
History: 1979 c. 313
; 1997 a. 27
; Stats. 1997 s. 149.11; 2005 a. 74
, ss. 41
See also ch. HFS 119
, Wis. adm. code.
The federal Employee Retirement Income Security Act (ERISA) preempts any state law that relates to employee benefit plans. General Split Corp. v. Mitchell, 523 F. Supp. 427
Rules relating to creditable coverage.
The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a)
and that determine the creditable coverage to which s. 149.10 (2t) (b)
applies. The rules shall comply with section 2701 (c) of P.L. 104-191
Eligibility determination. 149.12(1)
Except as provided in subs. (1m)
, and (3)
, the authority shall certify as eligible a person who is covered by Medicare because he or she is disabled under 42 USC 423
, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV, or an antibody to HIV, a person who is an eligible individual, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:
A notice of rejection of coverage from 2 or more insurers.
A notice of cancellation of coverage from one or more insurers.
A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.
A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.
The authority may not certify a person as eligible under circumstances requiring notice under sub. (1) (a)
if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in s. 633.01
Except as provided in subd. 2.
, no person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.
2. Subdivision 1.
does not apply to any person who is an eligible individual or to any person who terminates coverage under the plan because he or she is eligible to receive medical assistance benefits.
No person on whose behalf the plan has paid out $1,000,000 or more is eligible for coverage under the plan.
Except as provided in subd. 2.
, no person who is 65 years of age or older is eligible for coverage under the plan.
A person who has coverage under the plan on the date on which he or she attains the age of 65 years.
No person who is eligible for creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1.
, that is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
Except as provided in subd. 2.
, no person who is eligible for medical assistance is eligible for coverage under the plan.
2. Subdivision 1.
does not apply to a person who is otherwise eligible for coverage under the plan and who is eligible for only any of the following types of medical assistance:
A person is not eligible for coverage under the plan if the person is eligible for any of the following:
Except as provided in pars. (b)
, no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.
Persons for whom deductible or coinsurance amounts are paid or reimbursed under ch. 47
for vocational rehabilitation, under s. 49.68
for renal disease, under s. 49.685 (8)
for hemophilia, under s. 49.683
for cystic fibrosis, under s. 253.05
for maternal and child health services or under s. 49.686
for the cost of drugs for the treatment of HIV infection or AIDS are not ineligible for coverage under the plan by reason of such payments or reimbursements.
Persons for whom premium costs for health insurance coverage are subsidized under s. 252.16
are not ineligible for coverage under the plan by reason of such payments.
Subject to subs. (1m)
, and (3)
, the authority may establish criteria that would enable additional persons to be eligible for coverage under the plan. The authority shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.
The authority shall establish policies for determining and verifying the continued eligibility of an eligible person.
See also chs. HFS 119
8.42, Wis. adm. code.
Participation of insurers. 149.13(1)
Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2)
would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the authority of the insurers participating in the cost of administering the plan.
Every participating insurer shall share in the operating, administrative and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.
Each insurer's proportion of participation under sub. (2)
shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the authority.
If the authority or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600
is not adequate to permit the commissioner or the authority to carry out the commissioner's or authority's responsibilities under this subchapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the commissioner and authority to make the determinations required under this subchapter.
Notwithstanding subs. (1)
, the authority, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan. Neither the commissioner nor the authority may assess any type of insurance that was not being assessed as of December 1, 2005, or any type of insurer that was not being assessed as December 1, 2005.
The plan shall offer coverage for each eligible person in an annually renewable policy. If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by Medicare. If an eligible person is eligible for a type of medical assistance specified in s. 149.12 (2) (f) 2.
, the plan shall not pay or reimburse the person for expenses paid for by Medical Assistance.