AB876: Bill Text

AB876, s. 8 Section 8. 25.57 of the statutes is created to read:

AB876,9,12 25.57 Small employer catastrophic care program fund. There is established a separate nonlapsible trust fund designated as the small employer catastrophic care program fund, to consist of:

AB876,9,13 (1) The moneys transferred under s. 20.145 (1) (g).

AB876,9,14 (2) Insurer assessments established under s. 635.30 (3) (a) 2.

AB876,9,15 (3) Provider assessments established under s. 635.30 (3) (a) 3.

AB876,9,16 (4) Premiums established under s. 635.30 (3) (a) 4.

AB876, s. 9 Section 9. 40.51 (6) of the statutes is renumbered 40.51 (6) (a) and amended to read:

AB876,9,24 40.51 (6) (a) This Except as provided in par. (b), the state shall offer to all of its employees at least 2 insured or uninsured health care coverage plans providing substantially equivalent hospital and medical benefits, including a health maintenance organization or a preferred provider plan, if those health care plans are determined by the group insurance board to be available in the area of the place of employment and are approved by the group insurance board.

AB876, s. 10 Section 10. 40.51 (6) (b) of the statutes is created to read:

AB876,10,7 40.51 (6) (b) Notwithstanding s. 40.03 (6) (c), in addition to the health care coverage plans offered under par. (a), the state shall also offer to all of its employees a defined contribution plan that permits employees to choose the level of premiums, deductibles, and co-payments and to select the hospital and medical benefits offered under the plan, but only if the group insurance board determines that such a defined contribution plan is available in the area of the place of employment and approves the plan.

AB876, s. 11 Section 11. 40.98 (2) (h) of the statutes is created to read:

AB876,10,14 40.98 (2) (h) The department may seek funding from any person for the payment of costs of designing, marketing, and contracting for or providing administrative services under the health care coverage program and for lapsing to the general fund any amount required under sub. (6m). Any moneys received by the department under this paragraph shall be credited to the appropriation account under s. 20.515 (2) (g).

AB876, s. 12 Section 12. 40.98 (6m) of the statutes is created to read:

AB876,10,24 40.98 (6m) The secretary of administration shall lapse from the appropriation under s. 20.515 (2) (g) to the general fund the amounts necessary to repay the loan under s. 601.34 when the secretary of administration, after consulting with the board, determines that funds in the appropriation under s. 20.515 (2) (g) are sufficient to make the lapse. The amounts that are required to be lapsed under s. 20.515 (2) (g) shall equal the amount necessary to pay all principal and interest costs on the loan, less any amount that is lapsed to the general fund under s. 20.515 (2) (a) at the end of the 2001-03 fiscal biennium. The secretary of administration may lapse the amounts under s. 20.515 (2) (g) in installments.

AB876, s. 13 Section 13. 149.12 (1) (intro.) of the statutes is amended to read:

AB876,11,8 149.12 (1) (intro.) Except as provided in subs. (1m) and, (2), and (4), the board or 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:

AB876, s. 14 Section 14. 149.12 (4) of the statutes is created to read:

AB876,11,17 149.12 (4) Notwithstanding subs. (1) to (3), the board may, in its discretion, certify as eligible for coverage under the plan a person who applies for coverage after his or her enrollment in the program under s. 635.30 is terminated under s. 635.30 (4) (b), regardless of whether the person satisfies the eligibility requirements under subs. (1) to (3). The board shall determine whether a person who obtains coverage under the plan under this subsection and who does not satisfy the eligibility requirements under subs. (1) to (3) may remain covered under the plan after the program under s. 635.30 is no longer in operation.

AB876, s. 15 Section 15. 149.14 (6) (a) of the statutes is amended to read:

AB876,11,23 149.14 (6) (a) Except as provided in par. pars. (b) and (c), 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.

AB876, s. 16 Section 16. 149.14 (6) (c) of the statutes is created to read:

AB876,12,5 149.14 (6) (c) A person who obtains coverage under the plan under s. 149.12 (4) and whose application for coverage was received within 63 after his or her enrollment in the program under s. 635.30 was terminated under s. 635.30 (4) (b), may not be subject to any preexisting condition exclusion under the plan, as provided in s. 635.30 (4) (b).

AB876, s. 17 Section 17. 601.34 of the statutes is created to read:

AB876,12,21 601.34 Loan to general fund. No later than the first day of the 2nd month after the effective date of this section .... [revisor inserts date], an amount equal to $850,000 shall be lapsed from the appropriation account under s. 20.145 (1) (g) to the general fund. The amount lapsed from the appropriation account shall be considered a loan to the general fund and interest shall accrue on the amount lapsed at the average rate earned by the state on its deposits in the state investment fund during the period of the loan. The general fund shall repay the loan from moneys lapsed to the general fund from the appropriation under s. 20.515 (2) (a) at the end of the 2001-03 fiscal biennium, if any, and from moneys lapsed to the general fund from the appropriation under s. 20.515 (2) (g) in the amounts specified in s. 40.98 (6m). If the secretary of administration determines that the moneys lapsed from these appropriations will not be sufficient to repay the loan within a reasonable period of time, as determined by the secretary and the commissioner, the secretary shall credit the appropriation account under s. 20.145 (1) (g) from moneys in the general fund an amount sufficient to repay the loan.

AB876, s. 18 Section 18. 632.835 (2) (b) of the statutes, as created by 1999 Wisconsin Act 155, is amended to read:

AB876,13,6 632.835 (2) (b) Whenever If an adverse determination or an experimental treatment determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

AB876, s. 19 Section 19. 632.835 (2) (bg) of the statutes is created to read:

AB876,13,11 632.835 (2) (bg) Notwithstanding par. (b), an insurer is not required to provide the notice under par. (b) to an insured who uses the internal grievance procedure under s. 632.83 until the insurer sends it notice of the disposition of the internal grievance if all of the following apply:

AB876,13,16 1. The health benefit plan issued by the insurer contains a description of the independent review procedure under this section, including an explanation of the insured's rights under par. (d), how to request the review, the time within which the review must be requested, and how to obtain a current listing of independent review organizations certified under sub. (4).

AB876,13,19 2. The insurer includes on its explanation of benefits form a reference to the section of the policy or certificate that contains the description of the independent review procedure.

AB876, s. 20 Section 20. 635.25 of the statutes is created to read:

AB876,13,22 635.25 Catastrophic risk. (1) Definition. In this section, "board" means the small employer catastrophic reinsurance board.

AB876,14,2 (2) Thresholds for covered benefits. (a) By December 1, 2002, and every 2 years thereafter until December 1, 2006, every small employer insurer shall select, and submit a report to the commissioner that specifies, the small employer insurer's threshold level of covered benefits, which may be any of the following:

AB876,14,3 1. Fifty thousand dollars in a calendar year.

AB876,14,4 2. One hundred thousand dollars in a calendar year.

AB876,14,5 3. One hundred fifty thousand dollars in a calendar year.

AB876,14,6 4. Two hundred fifty thousand dollars in a calendar year.

AB876,14,9 (b) The threshold level of benefits specified in a report under par. (a) shall apply to each insured under every group health benefit plan issued to a small employer in this state by the small employer insurer submitting the report.

AB876,14,19 (c) For each of the 2 calendar years after the year in which a small employer insurer submits a report under par. (a), if the amount of covered benefits paid in a calendar year, beginning with 2004 and ending with 2008, by the small employer insurer on behalf of any insured under any group health benefit plan to which this section applies exceeds the threshold level of covered benefits specified in the report, the commissioner, at the direction of the board, shall reimburse the small employer insurer from the appropriation under s. 20.145 (1) (j), in accordance with the procedures established by rule under sub. (5) (e), for 80% of the amount paid by the small employer insurer in that calendar year in excess of the threshold level specified in the report.

AB876,14,23 (3) Premiums for reimbursements. (a) For every group health benefit plan issued or renewed to a small employer in this state on or between the dates specified by rule under sub. (5) (b), a small employer insurer shall charge a total premium that includes the premium amount established by rule under sub. (5) (a).

AB876,15,3 (b) By the date specified by rule under sub. (5) (c), a small employer insurer shall forward to the board the premiums established by rule under sub. (5) (a), in the manner required by rule under sub. (5) (d). The board shall credit all premium amounts received under this paragraph to the appropriation account under s. 20.145 (1) (j).

AB876,15,7 (c) In addition to the disclosures required under s. 635.11, before the issuance or renewal of a group health benefit plan to a small employer in this state on or between the dates specified by rule under sub. (5) (b), a small employer insurer shall disclose to the small employer all of the following:

AB876,15,9 1. The small employer insurer's current threshold level of covered benefits under sub. (2) (a) and the calendar years to which it applies.

AB876,15,12 2. The amount of the total premium that is attributable to coverage for the small employer insurer's threshold level of covered benefits and 20% of covered benefits in excess of that threshold level.

AB876,15,14 3. The amount of the total premium that is the premium amount established by rule under sub. (5) (a).

AB876,15,21 (4) Provider discounts. (a) The commissioner by rule shall establish provider discount rates for charges for covered services provided to insureds under group health benefit plans that are issued or renewed to small employers in this state on or between the dates specified by rule under sub. (5) (b). The commissioner may establish higher provider discount rates for covered benefits under group health benefit plans that are issued by small employer insurers that specify higher threshold levels under sub. (2) (a).

AB876,16,2 (b) Except for copayments, coinsurance, or deductibles required or authorized under a group health benefit plan, a provider of a covered service, drug, or device shall accept as payment in full for the covered service, drug, or device the discounted payment rate under par. (a) and may not bill the insured under the group health benefit plan who receives the service, drug, or device for any amount by which the charge is reduced under par. (a).

AB876,16,4 (5) Rules. The commissioner shall promulgate rules developed by the board for the operation of this section, including rules that do all of the following:

AB876,16,9 (a) Establish and periodically adjust the premium amounts that must be charged to small employers under sub. (3) (c) 3. The premium amounts under sub. (3) (c) 3. shall be based on an actuarily sound charge per covered individual that is calculated to generate sufficient moneys, in conjunction with provider discounts under sub. (4), to cover the reimbursements required under sub. (2) (c).

AB876,16,11 (b) Specify the dates that apply in sub. (3) (a), subject to the dates specified in par. (c) and sub. (2) (c).

AB876,16,14 (c) Specify the dates by which a small employer insurer must forward to the board the premiums established under par. (a). The first date by which the premiums must be forwarded to the board may not be later than July 1, 2003.

AB876,16,17 (d) Specify the procedures that small employer insurers must use for collecting, segregating, holding in trust, and forwarding to the board the premiums established under par. (a).

AB876,16,21 (e) Specify the procedures that small employer insurers must use for obtaining reimbursement under sub. (2) (c), including requirements for documenting the payment of covered benefits for determining whether a small employer insurer has paid its threshold level of covered benefits.

AB876, s. 21 Section 21. 635.30 of the statutes is created to read:

AB876,16,23 635.30 Pilot catastrophic care program. (1) In this section:

AB876,16,24 (a) "Board" means the small employer catastrophic care board.

AB876,17,2 (b) "Fiscal year" means the period beginning on July 1 and ending on the following June 30.

AB876,17,3 (c) "Fund" means the small employer catastrophic care program fund.

AB876,17,4 (d) "Health care coverage revenue" has the meaning given in s. 149.10 (3m).

AB876,17,5 (e) "Insurer" has the meaning given in s. 632.745 (15).

AB876,17,7 (f) "Program" means the pilot program established and administered under this section.

AB876,17,10 (g) "Provider" means a health care professional, as defined in s. 180.1901 (1m), a health care facility, as defined in s. 146.997 (1) (c), or a health care service or organization.

AB876,17,16 (2) Establishment and administration of program. (a) There is established a pilot catastrophic care program for employees who are eligible for coverage under group health benefit plans issued to small employers. The program shall operate for 5 years, beginning on January 1, 2003, in a region of the state that includes Winnebago County and that shall be determined and described by the commissioner by rule.

AB876,17,18 (b) The board shall oversee the operations of the program, and shall do all of the following:

AB876,17,20 1. Annually, by no later than April 30, establish a budget for the program for the next fiscal year.

AB876,17,23 2. Subject to sub. (3) (a) 4., establish the methodology for determining the premium to be charged a small employer for providing coverage under the program for an employee of the small employer.

AB876,18,3 3. Establish procedures for collecting and depositing in the fund the insurer assessments under sub. (3) (a) 2., the provider assessments under sub. (3) (a) 3., and the premiums under sub. (3) (a) 4.

AB876,18,7 4. Establish procedures for paying the costs of covered benefits for employees enrolled in the program, including procedures that small employer insurers must use for documenting and obtaining reimbursement of claims costs under sub. (6) (c), and for paying all other operating and administrative costs of the program.

AB876,18,22 5. Annually, by no later than April 30, based on data from the previous calendar year, perform a reconciliation with respect to program costs, the transfer to the fund under s. 20.145 (1) (g), insurer assessments under sub. (3) (a) 2., provider assessments under sub. (3) (a) 3., provider payment rate discounts under sub. (3) (b), and premiums under sub. (3) (a) 4. If the board determines that in the preceding calendar year the insurer assessments under sub. (3) (a) 2., or the provider assessments under sub. (3) (a) 3. in conjunction with the provider payment rate discounts under sub. (3) (b), were not equal to the transfer to the fund under s. 20.145 (1) (g), as required in sub. (3) (a) 2. and 3., the board shall make any necessary adjustments for the fiscal year beginning on the first July 1 after the reconciliation, by increasing or decreasing the insurer assessments under sub. (3) (a) 2., the provider assessments under sub. (3) (a) 3., or the provider payment rate discounts under sub. (3) (b) to reflect the amount by which the insurer assessments or provider assessments in conjunction with the provider payment rate discounts did not equal the amount of the transfer.

AB876,18,25 6. Provide for the procurement, in a competitive process, of a contract for the services of a qualified administrator to administer the program and to assist the board in its oversight of the program.

AB876,19,5 (3) Program funding. (a) In establishing the annual budget under sub. (2) (b) 1., the board shall determine and approve the amount of funding needed for the fiscal year to pay the anticipated costs of covered benefits for employees enrolled in the program and all other operating and administrative costs of the program. Funding for the program shall consist of all of the following:

AB876,19,7 1. The transfer to the fund from the appropriation account under s. 20.145 (1) (g).

AB876,19,18 2. Assessments paid by insurers that are established by the board and promulgated by the commissioner by rule and that annually equal the amount of the annual transfer under subd. 1. Each insurer's share of the assessment under this subdivision shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner, and shall be in the same ratio as the insurer's total health care coverage revenue for residents of this state during the preceding calendar year bears to the aggregate health care coverage revenue of all insurers for residents of this state, as determined by the commissioner. The commissioner may by rule exempt as a class those insurers whose share would be so minimal as not to exceed the estimated cost of levying the assessment.

AB876,19,25 3. Assessments paid by providers that are established by the board and promulgated by the commissioner by rule and that, in conjunction with the provider discounts established under par. (b), annually equal the amount of the annual transfer under subd. 1. Each provider's share of the assessment under this subdivision shall be determined as provided in the rule under this subdivision. The commissioner may by rule exempt as a class those providers whose share would be so minimal as not to exceed the estimated cost of levying the assessment.

AB876,20,5 4. The premiums described in sub. (5) (c) 2., which shall be established by the board and promulgated by the commissioner by rule, and which shall be calculated on the basis of the amount by which the sum of the amounts under subds. 1. to 3. is not sufficient to pay the anticipated costs of covered benefits for employees enrolled in the program and all other operating and administrative costs of the program.

AB876,20,8 (b) 1. Subject to par. (a) 3., the commissioner by rule shall establish provider discount rates for charges for covered services provided to employees enrolled in the program.

AB876,20,14 2. Except for copayments, coinsurance, or deductibles required or authorized under the group health benefit plan for which the employee is eligible under sub. (4) (a) 1., a provider of a covered service, drug, or device shall accept as payment in full for the covered service, drug, or device the discounted payment rate under subd. 1. and may not bill the employee who receives the service, drug, or device for any amount by which the charge is reduced under subd 1.

AB876,20,16 (4) Employee eligibility. (a) An employee may be enrolled in the program if all of the following apply:

AB876,20,19 1. The employee is eligible for coverage under a group health benefit plan that is issued or renewed by a small employer insurer to a small employer on or between the dates specified by rule under sub. (7) (c).

AB876,20,21 2. The small employer is located in the region determined by rule under sub. (2) (a).

AB876,20,25 3. When the small employer insurer applies health status underwriting factors under s. 635.05 for determining premiums under the group health benefit plan under subd. 1., the small employer insurer determines that the employee is eligible to enroll in the program by using the guidelines established by rule under sub. (7) (a).

AB876,21,1 4. The small employer agrees to enroll the employee in the program.

AB876,21,3 5. The small employer pays the additional premium described in sub. (5) (c) 2. for the enrolled employee's coverage under the program.

AB876,21,9 (b) If an employee who is enrolled in the program becomes ineligible under par. (a), the employee may apply for coverage under the health insurance risk-sharing plan under ch. 149. If the employee applies for and obtains coverage under that plan and his or her application for coverage was received within 63 days after his or her enrollment under the program was terminated under this paragraph, the employee may not be subject to any preexisting condition exclusion under that plan.

AB876,21,14 (5) Premiums. (a) For every group health benefit plan issued or renewed to a small employer that agrees to enroll in the program an employee who is eligible under sub. (4) (a), the small employer insurer shall charge a total premium that includes an amount established by rule under sub. (3) (a) 4. for the employee's coverage under the program.

AB876,21,17 (b) The small employer insurer shall forward to the board, in the manner and time required by rule under sub. (7) (d), the premium amounts that are charged for coverage under the program.

AB876,21,21 (c) In addition to the disclosures required under s. 635.11, upon the issuance or renewal of a group health benefit plan to a small employer that agrees to enroll an employee in the program, the small employer insurer shall disclose to the small employer all of the following:

AB876,21,24 1. The amount of the total premium that is attributable to coverage under the group health benefit plan for the small employer's employees who are not enrolled in the program.

AB876,22,2 2. The amount of the total premium that is attributable to an employee's coverage under the program and that is established by rule under sub. (3) (a) 4.