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.
If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 149.12
, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
(2) Major medical expense coverage. 149.14(2)(a)(a)
The plan shall provide every eligible person who is not eligible for Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit of $1,000,000 per covered individual.
The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under par. (a)
by the amounts paid under medicare.
In addition to the coverage under pars. (a)
, the plan shall offer to all eligible persons who are not eligible for Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L. 104-191
. Any such choice of coverage shall be major medical expense coverage. An eligible person who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the authority, among the coverages offered under this paragraph and par. (a)
. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under the plan. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under the plan and the person remained continuously covered under the plan up to the time of electing the new coverage.
Premium reductions under s. 149.165
and deductible subsidies and prescription drug copayment subsidies under s. 149.14 (5)
do not apply to the coverage offered under this paragraph.
(3) Covered expenses.
Covered expenses for coverage under the plan shall be the payment rates established by the authority for services provided by persons licensed under ch. 446
and certified under s. 49.45 (2) (a) 11.
Covered expenses for coverage under the plan shall also be the payment rates established by the authority for, at a minimum, the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448
or in another state and who is certified under s. 49.45 (2) (a) 11.
and if the service or article is provided by a provider certified under s. 49.45 (2) (a) 11.
Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.
Subject to the limits under subd. 1.
, services for the chronically mentally ill in community support programs operated under s. 51.421
Drugs requiring a physician's prescription.
For persons eligible for Medicare, services of a licensed skilled nursing facility, to the extent required by s. 632.895 (3)
and for not more than an aggregate 120 days during a calendar year, if the services are of the type that would qualify as reimbursable services under Medicare. Coverage under this paragraph that is not required by s. 632.895 (3)
is subject to any deductible and coinsurance requirements provided by the authority.
For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by s. 632.895 (3)
Use of radium or other radioactive materials.
Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.