March 30, 2001 - Introduced by Representative Albers, cosponsored by Senator
Moen, by request of Health Insurance Risk-Sharing Plan Board of Governors.
Referred to Committee on Health.
AB265,1,5 1An Act to amend 149.14 (5) (title), 149.14 (5) (b), 149.14 (5) (c), 149.14 (5) (e),
2149.146 (2) (am) 2. and 149.146 (2) (am) 3.; and to create 149.146 (2) (am) 5.
3of the statutes; relating to: copayments and coinsurance for prescription drugs
4under the health insurance risk-sharing plan and providing an exemption
5from emergency rule procedures.
Analysis by the Legislative Reference Bureau
The health insurance risk-sharing plan (HIRSP) under current law provides
major medical health insurance coverage for persons who are covered under
medicare because they are disabled, persons who have tested positive for HIV, and
persons who have been refused coverage, or coverage at an affordable price, in the
private health insurance market because of their mental or physical health
condition. Also eligible for coverage are persons who do not currently have health
insurance coverage, but who were covered under certain types of health insurance
coverage for at least 18 months in the past. HIRSP is administered by the
department of health and family services (DHFS), in conjunction with a plan
administrator and a board of governors (board).
For covered services obtained in a calendar year, a person with coverage under
HIRSP pays a deductible, and then pays coinsurance of 20% of covered costs that
exceed the deductible amount. HIRSP pays 100% of covered costs incurred by the
person during the remainder of the calendar year once the person has paid a specified
amount in deductible and coinsurance (out-of-pocket limit). Current law authorizes

DHFS to establish, by rule with the approval of the board, copayments for
prescription drug coverage, and provides that those copayments count toward the
out-of-pocket limit that a person must pay before HIRSP will pay 100% of the
person's covered costs.
This bill authorizes DHFS to establish for prescription drug coverage, in
addition to copayments, coinsurance rates and copayment and coinsurance
out-of-pocket limits over which HIRSP pays 100% of covered prescription drug
costs. Any amount or rate must be approved by the board. In addition, the bill
provides that amounts paid by a covered person in copayments and coinsurance for
prescription drugs are separate from, and do not count toward, the deductible and
coinsurance out-of-pocket limits that apply under current law to other covered
costs.
For further information see the state fiscal estimate, which will be printed as
an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB265, s. 1 1Section 1. 149.14 (5) (title) of the statutes is amended to read:
AB265,2,32 149.14 (5) (title) Deductibles, copayments and, coinsurance, and
3out-of-pocket limits
.
AB265, s. 2 4Section 2. 149.14 (5) (b) of the statutes is amended to read:
AB265,2,85 149.14 (5) (b) Except as provided in par. pars. (c) and (e), if the covered costs
6incurred by the eligible person exceed the deductible for major medical expense
7coverage in a calendar year, the plan shall pay at least 80% of any additional covered
8costs incurred by the person during the calendar year.
AB265, s. 3 9Section 3. 149.14 (5) (c) of the statutes is amended to read:
AB265,3,210 149.14 (5) (c) If Except as provided in par. (e), if the aggregate of the covered
11costs not paid by the plan under par. (b) and the deductible exceeds $500 for an
12eligible person receiving medicare, $2,000 for any other eligible person during a
13calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100%

1of all covered costs incurred by the eligible person during the calendar year after the
2payment ceilings under this paragraph are exceeded.
AB265, s. 4 3Section 4. 149.14 (5) (e) of the statutes is amended to read:
AB265,3,124 149.14 (5) (e) Subject to sub. (8) (b), the department may, by rule under s. 149.17
5(4), establish copayments for prescription drug coverage under sub. (3) (d) copayment
6amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits
7over which the plan will pay 100% of covered costs under sub. (3) (d)
. Any copayment
8amounts or rates amount, coinsurance rate, or out-of-pocket limit established are
9under this paragraph is subject to the approval of the board. Copayments and
10coinsurance
paid by an eligible person under this paragraph shall are separate from
11and do not
count toward the deductible and covered costs not paid by the plan under
12pars. (a) to (c).
AB265, s. 5 13Section 5. 149.146 (2) (am) 2. of the statutes is amended to read:
AB265,3,1714 149.146 (2) (am) 2. Except as provided in subd. subds. 3. and 5., if the covered
15costs incurred by the eligible person exceed the deductible for major medical expense
16coverage in a calendar year, the plan shall pay at least 80% of any additional covered
17costs incurred by the person during the calendar year.
AB265, s. 6 18Section 6. 149.146 (2) (am) 3. of the statutes is amended to read:
AB265,3,2419 149.146 (2) (am) 3. If Except as provided in subd. 5., if the aggregate of the
20covered costs not paid by the plan under subd. 2. and the deductible exceeds $3,500
21for any eligible person during a calendar year or $7,000 for all eligible persons in a
22family, the plan shall pay 100% of all covered costs incurred by the eligible person
23during the calendar year after the payment ceilings under this subdivision are
24exceeded.
AB265, s. 7 25Section 7. 149.146 (2) (am) 5. of the statutes is created to read:
AB265,4,9
1149.146 (2) (am) 5. Subject to s. 149.14 (8) (b), the department may, by rule
2under s. 149.17 (4), establish for prescription drug coverage under this section
3copayment amounts, coinsurance rates, and copayment and coinsurance
4out-of-pocket limits over which the plan will pay 100% of covered costs for
5prescription drugs. Any copayment amount, coinsurance rate, or out-of-pocket
6limit established under this subdivision is subject to the approval of the board.
7Copayments and coinsurance paid by an eligible person under this subdivision are
8separate from and do not count toward the deductible and covered costs not paid by
9the plan under subds. 1. to 3.
AB265, s. 8 10Section 8. Nonstatutory provisions.
AB265,4,1911 (1) Rules on drug copayments and coinsurance. The department of health and
12family services may use the procedure under section 227.24 of the statutes to
13promulgate rules authorized under section 149.14 (5) (e) of the statutes, as affected
14by this act, and section 149.146 (2) (am) 5. of the statutes, as created by this act.
15Notwithstanding section 227.24 (1) (a), (2) (b), and (3) of the statutes, the department
16is not required to provide evidence that promulgating a rule under this subsection
17as an emergency rule is necessary for the preservation of public peace, health, safety,
18or welfare and is not required to provide a finding of emergency for a rule
19promulgated under this subsection.
AB265, s. 9 20Section 9. Initial applicability.
AB265,4,2221 (1) This act first applies to policies under the health insurance risk-sharing
22plan that are issued or renewed on the effective date of this subsection.
AB265,4,2323 (End)
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