e. Any other reason that the department determines is a good cause reason.
(e) If a pregnant woman has health insurance coverage and her family income exceeds 200 percent of the poverty line, the woman is required, as a condition of eligibility, to maintain the health insurance coverage.
(f) If an individual with a family income that exceeds 150 percent of the poverty line had the health insurance coverage specified in par. (b) 1. but no longer has the coverage, if an individual who is an unborn child or an unborn child's mother, regardless of family income, had health insurance coverage but no longer has the coverage, or if a pregnant woman specified in par. (e) has health insurance coverage and does not maintain the coverage, the individual or pregnant woman is not eligible for BadgerCare Plus for the 3 calendar months following the month in which the insurance coverage ended without a good cause reason specified in par. (g).
(g) Any of the following is a good cause reason for purposes of par. (f):
1. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employment ended for a reason other than voluntary termination, unless the voluntary termination was a result of the incapacitation of the subscriber or because on an immediate family member's health condition.
2. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, the subscriber changed employers, and the new employer does not offer health insurance coverage.
3. The individual or pregnant woman was covered by a group health plan that was provided by a subscriber through his or her employer, and the subscriber's employer discontinued health plan coverage for all employees.
4. The pregnant woman's coverage was continuation coverage and the continuation coverage was exhausted in accordance with
29 CFR 2590.701-
2 (4).
5. The individual's or pregnant woman's coverage terminated due to the death or change in marital status of the subscriber.
6. Any other reason determined by the department to be a good cause reason.
(9) Employer verification of insurance coverage. (a) 1. Except as provided in subd. 2., for an applicant or recipient with a family income that exceeds 150 percent of the poverty line, the department shall verify insurance coverage and access information directly with the employer through which the applicant or recipient may have health insurance coverage or access to coverage.
2. Subdivision 1. does not apply to any of the following:
a. A pregnant woman.
b. A child described in sub. (4) (a) 2. or (b) 2.
c. An individual described in sub. (4) (a) 5.
(b) An employer that receives a request from the department for insurance coverage and access to coverage information shall supply the information requested by the department in the format specified by the department within 30 calendar days after receiving the request.
(c) 1. Subject to subds. 2. and 3., an employer that does not comply with the requirements under par. (b) shall be required to pay, within 45 days after the requested information was due, a penalty equal to the full per member per month cost of coverage under BadgerCare Plus for the individual about whom the information is requested, and for each of the individual's family members with coverage under BadgerCare Plus, for each month in which the individual and the individual's family members are covered before the employer provides the information.
2. An employer with fewer than 250 employees may not be required to pay more than $1,000 in penalties under this paragraph that are attributable to any 6-month period. An employer with 250 or more employees may not be required to pay more than $15,000 in penalties under this paragraph that are attributable to any 6-month period.
3. Notwithstanding subd. 1., an employer shall not be subject to any penalties if the employer, at least once per year, timely provides to the department, in the manner and format specified by the department, information from which the department may determine whether the employer provides its employees with access to health insurance coverage.
4. All penalty assessments collected under this paragraph shall be credited to the appropriation accounts under s. 20.435 (4) (jw) and (jz).
(d) An employer may contest a penalty assessment under par. (c) by sending a written request for hearing to the division of hearings and appeals in the department of administration. Proceedings before the division are governed by ch. 227.
(10) Cost sharing. (a) Copayments. Except as provided in s. 49.45 (18) (am), all cost-sharing provisions under s. 49.45 (18) apply to a recipient with coverage of the benefits described in s. 49.46 (2) (a) and (b) to the same extent as they apply to a person eligible for medical assistance under s. 49.46, 49.468, or 49.47.
(b) Premiums. 1. Except as provided in subd. 4., a recipient who is an adult, who is not a pregnant woman, and whose family income is greater than 150 percent but not greater than 200 percent of the poverty line shall pay a premium for coverage under BadgerCare Plus that does not exceed 5 percent of his or her family income. If the recipient has self-employment income and is eligible under sub. (4) (b) 4., the premium may not exceed 5 percent of family income calculated before depreciation was deducted.
2. Except as provided in subds. 3. and 4., a recipient who is a child whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for a child with a family income of 300 percent of the poverty line.
3. Except as provided in subd. 4., a recipient who is an unborn child, or a pregnant woman eligible under sub. (4) (b) 1., whose family income is greater than 200 percent of the poverty line shall pay a premium for coverage of the benefits described in sub. (11) that does not exceed the full per member per month cost of coverage for an adult with a family income of 300 percent of the poverty line.
4. None of the following shall pay a premium:
a. A child who is a Native American or an Alaskan Native with a family income that does not exceed 300 percent of the poverty line.
b. A child who is eligible under sub. (4) (a) 2. or (b) 2.
c. A child whose family income does not exceed 200 percent of the poverty line.
d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.
e. A child who obtains eligibility under sub. (7) (b) 2.
f. An individual who is eligible under sub. (4) (a) 5.
5. If a recipient who is required to pay a premium under this paragraph or under sub. (2m) or (4) (c) does not pay a premium when due, the recipient's coverage terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar months following the date on which the recipient's coverage terminated.
(11) Benchmark plan benefits and copayments. Recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:
(a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.
(b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.
(c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.
(d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.
(e) Laboratory and X-ray services, including mammography.
(f) Home health services, limited to 60 visits per year.
(g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).
(L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.
(m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.
(n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.
(o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.
(p) Early childhood developmental services, for children under 6 years of age.
(q) Smoking cessation treatment, for pregnant women only.
(r) Prenatal care coordination, for pregnant women at high risk only.
(11m) Provider payments and requirements. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.
(12) Rules; notice of effective date. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.
2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.
(b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.
20,1608
Section
1608. 49.473 (2) (a) of the statutes is amended to read:
49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.
20,1610
Section
1610. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).
20,1611
Section
1611. 49.475 (1) (ag) of the statutes is created to read:
49.475 (1) (ag) "Covered entity" means any of the following that is not an insurer:
1. A nonprofit hospital, as defined in s. 46.21 (2) (m).
2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.
3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.
20,1612
Section
1612. 49.475 (1) (am) of the statutes is created to read:
49.475 (1) (am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.
20,1613
Section
1613. 49.475 (1) (c) of the statutes is created to read:
49.475 (1) (c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:
1. Dispensation of prescription drugs by mail.
2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.
3. Clinical formulary development and management services.
4. Rebate contracting and administration.
5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.
20,1614
Section
1614. 49.475 (1) (d) of the statutes is created to read:
49.475 (1) (d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.
20,1615
Section
1615. 49.475 (1) (e) of the statutes is created to read:
49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:
1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.
2. An enrollee of family care.
3. A recipient of the Badger Care health care program.
4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.
5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.
6. A woman who receives services that are reimbursed under s. 255.06.
20,1616
Section
1616. 49.475 (1) (f) of the statutes is created to read:
49.475 (1) (f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:
1. An insurer.
2. An employee benefit plan described in
29 USC 1003 (a) that is not exempt under
29 USC 1003 (b) and is not a multiple employer welfare arrangement.
3. A service benefit plan, as specified in
42 USC 1396a (25) (I).
4. A pharmacy benefits manager.
