149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 619.10 149.10 (2t) (a) and that determine the creditable coverage to which s. 619.10 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.
27,4826
Section 4826
. 619.12 (title) of the statutes is renumbered 149.12 (title).
27,4827
Section 4827
. 619.12 (1) of the statutes is renumbered 149.12 (1), and 149.12 (1) (intro.), as renumbered, is amended to read:
149.12 (1) (intro.) Except as provided in subs. (1m) and (2), the board or administering carrier plan administrator 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:
27,4828
Section 4828
. 619.12 (1m) (intro) and (a) of the statutes are consolidated, renumbered 149.12 (1m) and amended to read:
149.12 (1m) The board or administering carrier plan administrator may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by one of the following: (a) An an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.
27,4829
Section 4829
. 619.12 (1m) (b) of the statutes is repealed.
27,4830b
Section 4830b. 619.12 (2) (b) of the statutes is renumbered 149.12 (2) (b) and amended to read:
149.12 (2) (b) 1. 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 receiving, or is eligible to receive, medical assistance benefits.
27,4830c
Section 4830c. 619.12 (2) (c) of the statutes is renumbered 149.12 (2) (c) and amended to read:
149.12 (2) (c) No person on whose behalf the plan has paid out $500,000 $1,000,000 or more is eligible for coverage under the plan.
27,4830d
Section 4830d. 619.12 (2) (d) of the statutes is renumbered 149.12 (2) (d) and amended to read:
149.12 (2) (d) No Except for a person who is an eligible individual, no person who is 65 years of age or older is eligible for coverage under the plan.
27,4830ec
Section 4830ec. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (2) (e) and amended to read:
149.12 (2) (e) No person who is eligible for
health care benefits creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
27,4830em
Section 4830em. 619.12 (2) (e) 1. of the statutes is renumbered 619.12 (2) (e) and amended to read:
619.12 (2) (e) Except as provided in subd. 2., no No person who is eligible for health care benefits, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
27,4830f
Section 4830f. 619.12 (2) (e) 2. of the statutes is repealed.
27,4830g
Section 4830g. 619.12 (2) (e) 3. of the statutes is repealed.
27,4831
Section 4831
. 619.12 (3) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (3), and 149.12 (3) (c), as renumbered, is amended to read:
149.12 (3) (c) The commissioner, in consultation with the board, department may promulgate rules specifying other deductible or coinsurance amounts that, if paid or reimbursed for persons, will not make the persons ineligible for coverage under the plan.
27,4831c
Section 4831c. 619.12 (3) (a) of the statutes is amended to read:
619.12 (3) (a) Except as provided in pars. (b)
and to (c), 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.
27,4831e
Section 4831e. 619.12 (3) (bm) of the statutes is created to read:
619.12 (3) (bm) 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.
27,4832b
Section 4832b. 619.123 of the statutes is repealed.
27,4833
Section 4833
. 619.125 of the statutes is renumbered 149.125 and amended to read:
149.125 Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the board department, to fund administrative expenses.
27,4834
Section 4834
. 619.13 (title) of the statutes is renumbered 149.13 (title).
27,4835
Section 4835
. 619.13 (1) (a) of the statutes is renumbered 149.13 (1) and amended to read:
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 par. (b) sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department of the insurers participating in the cost of administering the plan.
27,4836
Section 4836
. 619.13 (1) (b) of the statutes is renumbered 149.13 (2) and amended to read:
149.13 (2) Except as provided by a rule promulgated under s. 619.145 (4), every 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.
27,4837
Section 4837
. 619.13 (1) (c) of the statutes is repealed.
27,4838
Section 4838
. 619.13 (1) (d) of the statutes is renumbered 149.13 (3) and amended to read:
149.13 (3) (a) Each insurer's proportion of participation under par. (b) 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 department under s. 149.143 (2) (a) 3.
(b) If the department or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the department, the commissioner or the board to carry out the department's, commissioner's or the board's responsibilities under this subchapter chapter, the commissioner may shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and the board to make the determinations required under this subchapter chapter.
27,4839c
Section 4839c. 619.13 (2) of the statutes is repealed.
27,4840c
Section 4840c. 619.135 (title) of the statutes is renumbered 149.144 (title) and amended to read:
149.144 (title) Insurer
Adjustments to insurer assessments and provider payment rates for premium and deductible reductions.
27,4841c
Section 4841c. 619.135 (1) of the statutes is repealed.
27,4845c
Section 4845c. 619.135 (2) of the statutes is renumbered 149.144 and amended to read:
149.144 If the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah) are insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), or the commissioner department determines that the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah) will be insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), the commissioner department shall, by rule, increase adjust in equal proportions the amount of the assessment under sub. (1) (a) or levy an assessment against every insurer, or a combination of both, set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to s. 149.143 (1) (b) 1., sufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a). The department shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.
27,4846b
Section 4846b. 619.135 (3) of the statutes is repealed.
27,4847
Section 4847
. 619.14 (title) of the statutes is renumbered 149.14 (title).
27,4848
Section 4848
. 619.14 (1) of the statutes is renumbered 149.14 (1), and 149.14 (1) (b), as renumbered, is amended to read:
149.14 (1) (b) 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. 619.12 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
27,4849
Section 4849
. 619.14 (2) of the statutes is renumbered 149.14 (2), and 149.14 (2) (a), as renumbered, is amended to read:
149.14 (2) (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 sub. (3) and deductible and coinsurance payments authorized under sub. (5), up to a lifetime limit of $500,000
$1,000,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.
27,4850
Section 4850
. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14 (3) (intro.) and (c) 3., as renumbered, are amended to read:
149.14 (3) Covered expenses. (intro.) Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e) or by the department under s. 149.143 or 149.144, covered expenses for the coverage under this section shall be the usual and customary charges for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e)
or by the department under s. 149.143 or 149.144, covered expenses for the coverage under this section shall also be the usual and customary charges for the following services and articles when
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.:
(c) 3. Subject to the limits under subd. 2. and to rules promulgated by the commissioner department, services for the chronically mentally ill in community support programs operated under s. 51.421.
27,4851
Section 4851
. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14 (4) (intro.), (a) and (m), as renumbered, are amended to read:
149.14 (4) Exclusions. (intro.) Covered expenses for the coverage under this section shall not include the following:
(a) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect. Breast reconstruction of the affected tissue incident to a mastectomy shall not be considered treatment for cosmetic purposes.
(m) Experimental treatment, as determined by the board or its designee department.
27,4852c
Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title) and amended to read:
149.14 (5) (title) Premiums, deductibles Deductibles and coinsurance.
27,4853
Section 4853
. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and amended to read:
149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter chapter for major medical expense coverage required under this section. For coverage offered to those persons eligible for medicare, the plan shall offer a deductible equal to the deductible charged by part A of title XVIII of the federal social security act, as amended. The deductible amounts for all other eligible persons shall be dependent upon household income as determined under s. 619.165 149.165. For eligible persons under s. 619.165 (1) (b) 1. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other eligible persons who are not eligible for medicare, the deductible shall be $1,000. With respect to all eligible persons, expenses used to satisfy the deductible during the last 90 days of a calendar year shall also be applied to satisfy the deductible for the following calendar year. The schedule of premiums shall be promulgated by rule by the commissioner. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.
27,4854c
Section 4854c. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b).
27,4855c
Section 4855c. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c)
27,4856
Section 4856
. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and amended to read:
149.14 (5) (d) Notwithstanding pars. (a) to (c), the board department may establish different deductible amounts, a different coinsurance percentage and different covered costs and deductible aggregate amounts from those specified in pars. (a) to (c) in accordance with cost containment provisions established by the commissioner department under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 149.17 (4).
27,4856v
Section 4856v. 619.14 (5) (e) of the statutes is amended to read:
619.14 (5) (e) Using the procedure under s. 227.24, the commissioner may promulgate rules under par. (a) or s. 619.146 (2) (b) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under par. (a) or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner is not required to make a finding of emergency.
27,4857c
Section 4857c. 619.14 (5) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is repealed.
27,4858b
Section 4858b. 619.14 (6) of the statutes is renumbered 619.14 (6) (a) and amended to read:
619.14 (6) (a) No Except as provided in par. (b), no person who obtains coverage under the plan may be covered for any preexisting condition during the first 6 months of coverage under the plan if the person was diagnosed or treated for that condition during the 6 months immediately preceding the filing of an application with the plan.
27,4858c
Section 4858c. 619.14 (6) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.14 (6).
27,4858d
Section 4858d. 619.14 (6) (b) of the statutes is created to read:
619.14 (6) (b) An eligible individual who obtains coverage under the plan on or after the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion under the plan. An eligible individual who is covered under the plan on the effective date of this paragraph .... [revisor inserts date], may not be subject to any preexisting condition exclusion on or after the effective date of this paragraph .... [revisor inserts date].
27,4859
Section 4859
. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14 (7) (b) and (c), as renumbered, are amended to read:
149.14 (7) (b) The board department has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.
(c) The board department is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. Section 814.03 (3) applies to the department under this paragraph.
27,4860
Section 4860
. 619.145 of the statutes is repealed.
27,4860c
Section 4860c. 619.146 of the statutes is created to read:
619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14, the plan shall offer to all eligible persons a choice of coverage, as described in section 2744 (a) (1) (C) of P.L. 104-191. Any such choice of coverage shall be major medical expense coverage.
(b) An eligible person may elect once each year, at the time and according to procedures established by the board, among the coverages offered under this section and s. 619.14. 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 this subchapter. 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 this subchapter and the person remained continuously covered under this subchapter up to the time of electing new coverage.
(2) (a) Except as specified by the board, the terms of coverage under s. 619.14, including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 do not apply to the coverage offered under this section.
(b) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 by the same percentage as the percentage difference between the following:
1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14.
2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as the coverage offered under this section.
27,4860d
Section 4860d. 619.146 of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.146, and 149.146 (1) (a) and (b) and (2) (a) and (b) (intro.) and 1., as renumbered, are amended to read:
149.146 (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14
149.14, the plan shall offer to all eligible persons 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.
(b) An eligible person may elect once each year, at the time and according to procedures established by the board department, among the coverages offered under this section and s. 619.14 149.14. 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 this subchapter chapter. 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 this subchapter chapter and the person remained continuously covered under this subchapter chapter up to the time of electing the new coverage.
(2) (a) Except as specified by the board department, the terms of coverage under s. 619.14 149.14, including deductible reductions under s. 619.14 149.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 149.165 do not apply to the coverage offered under this section.
(b) (intro.) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner department, as provided in s. 149.143. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 149.14 by the same percentage as the percentage difference between the following:
