SB466: Bill Text

SB466,8,4 149.13 (4) Notwithstanding subs. (1) to (3), the department, with the agreement of the commissioner and the board, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan.

SB466, s. 17 Section 17. 149.132 of the statutes is created to read:

SB466,8,12 149.132 Participation of manufacturers and labelers. (1) Any manufacturer or labeler of prescription drugs that are sold, or otherwise provided, to persons in this state who receive health care coverage benefits under the Medical Assistance program under subch. IV of ch. 49, the Badger Care health care program under s. 49.665, or the prescription drug assistance for elderly persons program under s. 49.688 is required to sell prescription drugs for the prescribed use and purchase by eligible persons covered under the plan.

SB466,8,19 (2) As a condition of coverage under the plan of the prescription drugs of a manufacturer or labeler, the manufacturer or labeler shall pay an assessment on the total claims that the plan paid, in the previous calendar year, to pharmacists and pharmacies for the prescription drugs of the manufacturer or labeler. The assessment amount per claim shall be equal to the rebate paid under the Medical Assistance program by the manufacturer or labeler for the prescription drug that is the subject of the claim.

SB466,8,24 (3) The plan administrator shall notify each manufacturer and each labeler of the amount paid by the plan in claims for the prescription drugs of each manufacturer and labeler and shall advise the board and the department of the amounts. The department shall levy and collect the assessments and deposit the amounts collected in the health insurance risk-sharing plan fund.

SB466, s. 18 Section 18. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and amended to read:

SB466,9,15 149.14 (3) Covered expenses. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department board under ss. 149.143 and 149.144, covered expenses for the coverage under this section shall be the payment rates established by the department under s. 149.142 for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department board under ss. 149.143 and 149.144, covered expenses for the coverage under this section shall also be the payment rates established by the department under s. 149.142 for the following services and articles specified by the board 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.:

SB466, s. 19 Section 19. 149.14 (3) (a) to (r) of the statutes are repealed.

SB466, s. 20 Section 20. 149.14 (4) of the statutes is repealed.

SB466, s. 21 Section 21. 149.14 (4c) of the statutes is repealed.

SB466, s. 22 Section 22. 149.14 (5) (d) of the statutes is amended to read:

SB466,9,24 149.14 (5) (d) Notwithstanding pars. (a) to (c), the department board 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 department board under s. 149.17 (4).

SB466, s. 23 Section 23. 149.14 (5) (e) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,10,13 149.14 (5) (e) Subject to sub. (8) (b), the department board may, by rule under s. 149.17 (4), establish for prescription drug coverage under sub. (3) (d) this section copayment amounts, coinsurance rates, and copayment and coinsurance out-of-pocket limits over which the plan will pay 100% 100 percent of covered costs under sub. (3) (d) for prescription drugs. The department board may provide subsidies for prescription drug copayment amounts paid by eligible persons under s. 149.165 (2) (a) 1. to 5. Any copayment amount, coinsurance rate, or out-of-pocket limit established under this paragraph is subject to the approval of the board. Copayments and coinsurance paid by an eligible person under this paragraph are separate from and do not count toward the deductible and covered costs not paid by the plan under pars. (a) to (c).

SB466, s. 24 Section 24. 149.14 (5m) (c) of the statutes is amended to read:

SB466,10,16 149.14 (5m) (c) Other economic factors that the department and the board consider considers relevant.

SB466, s. 25 Section 25. 149.14 (7) (b) and (c) of the statutes are amended to read:

SB466,10,21 149.14 (7) (b) The department board has a cause of action against an eligible participant person for the recovery of the amount of benefits paid which that 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.

SB466,10,25 (c) The department board 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 board under this paragraph.

SB466, s. 26 Section 26. 149.14 (8) of the statutes is amended to read:

SB466,11,7 149.14 (8) Applicability of medical assistance provisions. (a) Except as provided in par. (b), the department board may, by rule under s. 149.17 (4), apply to the plan the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under subch. IV of ch. 49. The board shall consult with the department as necessary in the application of the utilization and cost control procedures specified in this paragraph.

SB466,11,10 (b) The department board may not apply to eligible persons for covered services or articles the same copayments that apply to recipients of medical assistance under subch. IV of ch. 49 for services or articles covered under that program.

SB466, s. 27 Section 27. 149.142 (1) of the statutes is amended to read:

SB466,11,21 149.142 (1) (a) Except as provided in par. (b), the department board shall establish payment rates for covered expenses that consist of the allowable charges paid under s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department board. The rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the same methodology that applies to medical assistance under subch. IV of ch. 49, the department board shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The board shall consult with the department in establishing the payment and reimbursement rates under this paragraph.

SB466,12,2 (b) The payment rate for a prescription drug shall be the allowable charge paid under s. 49.46 (2) (b) 6. h. for the prescription drug. Notwithstanding s. 149.17 (4), the department board may not reduce the payment rate for prescription drugs below the rate specified in this paragraph, and the rate may not be adjusted under s. 149.143 or 149.144.

SB466, s. 28 Section 28. 149.142 (3) of the statutes is created to read:

SB466,12,8 149.142 (3) Whenever a claim is processed for payment, the adjustment of a provider's payment rate under sub. (1) and any adjustment under s. 149.143 or 149.144 shall be calculated and applied on a per-claim basis. The adjustment shall be disclosed on the explanation-of-benefits form provided to the eligible person and to the provider.

SB466, s. 29 Section 29. 149.143 (1) (intro.) of the statutes is amended to read:

SB466,12,15 149.143 (1) (intro.) The department shall pay or recover the operating costs of the plan from the appropriation under s. 20.435 (4) (v) and administrative costs of the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining premiums, insurer assessments, and provider payment rate adjustments, the department board shall apportion and prioritize responsibility for payment or recovery of plan costs from among the moneys constituting the fund as follows:

SB466, s. 30 Section 30. 149.143 (1) (am) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,12,19 149.143 (1) (am) A total of 60% 60 percent from the following sources, calculated as follows:

SB466,13,3 1. First, from premiums from eligible persons with coverage under s. 149.14 (2) (a) set at a rate that is 140% 140 percent to 150% 150 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) set in accordance with s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144, and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).

SB466,13,5 2. Second, from moneys specified under sub. (2m), to the extent that the amounts under subd. 1. are insufficient to pay 60% 60 percent of plan costs.

SB466,13,16 3. Third, by increasing premiums from eligible persons with coverage under s. 149.14 (2) (a) to more than the rate at which premiums were set under subd. 1. but not more than 200% 200 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan and from eligible persons with coverage under s. 149.14 (2) (b) by a comparable amount in accordance with s. 149.14 (5m), including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144, and by increasing premiums from eligible persons with coverage under s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under subds. 1. and 2. are insufficient to pay 60% 60 percent of plan costs.

SB466,13,21 4. Fourth, notwithstanding par. (bm), by increasing insurer assessments, excluding assessments under s. 149.144, and adjusting provider payment rates, subject to s. 149.142 (1) (b) and excluding adjustments to those rates under s. 149.144, in equal proportions and to the extent that the amounts under subds. 1. to 3. are insufficient to pay 60% 60 percent of plan costs.

SB466, s. 31 Section 31. 149.143 (1) (bm) (intro.) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,13,24 149.143 (1) (bm) (intro.) A total of 40% 40 percent as follows:

SB466, s. 32 Section 32. 149.143 (1) (bm) 1. of the statutes, as affected by 2003 Wisconsin Act 33, is renumbered 149.143 (1) (bm) 2m. a.

SB466, s. 33 Section 33. 149.143 (1) (bm) 1m. of the statutes is created to read:

SB466,14,5 149.143 (1) (bm) 1m. First, from manufacturer and labeler assessments under s. 149.132.

SB466, s. 34 Section 34. 149.143 (1) (bm) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is renumbered 149.143 (1) (bm) 2m. b.

SB466, s. 35 Section 35. 149.143 (1) (bm) 2m. (intro.) of the statutes is created to read:

SB466,14,9 149.143 (1) (bm) 2m. (intro.) The remainder as follows:

SB466, s. 36 Section 36. 149.143 (2) (a) (intro.) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,14,16 149.143 (2) (a) (intro.) Prior to each plan year, the department board shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under s. 149.165 (2) and (3), the deductible reductions under s. 149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5) (e) for the new plan year and do all of the following:

SB466, s. 37 Section 37. 149.143 (2) (a) 1. a. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,14,24 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium, deductible, and prescription drug copayment subsidies under s. 149.144 and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60% 60 percent of the estimated plan costs for the new plan year.

SB466, s. 38 Section 38. 149.143 (2) (a) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,9 149.143 (2) (a) 2. After making the determinations under subd. 1., by rule set premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in the manner specified in sub. (1) (am) 1. and 3. and such that a rate for coverage under s. 149.14 (2) (a) is approved by the board and is not less than 140% 140 percent nor more than 200% 200 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan.

SB466, s. 39 Section 39. 149.143 (2) (a) 3. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,16 149.143 (2) (a) 3. By rule, after estimating the amount of manufacturer and labeler assessments that will be received under sub. (1) (bm) 1m., set the total insurer assessments under s. 149.13 for the new plan year by estimating and setting the assessments at the amount necessary to equal the amounts specified in sub. (1) (am) 4. and (bm) 1. 2m. a. and notify the commissioner of the amount.

SB466, s. 40 Section 40. 149.143 (2) (a) 4. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,15,24 149.143 (2) (a) 4. By the same rule as under subd. 3., after estimating the amount of the manufacturer and labeler assessments that will be received under sub. (1) (bm) 1m., adjust the provider payment rate for the new plan year, subject to s. 149.142 (1) (b), by estimating and setting the rate at the level necessary to equal the amounts specified in sub. (1) (am) 4. and (bm) 2. 2m. b. and as provided in s. 149.145.

SB466, s. 41 Section 41. 149.143 (2) (b) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,8 149.143 (2) (b) In setting the premium rates under par. (a) 2., the insurer assessment amount under par. (a) 3., and the provider payment rate under par. (a) 4. for the new plan year, the department board shall include any increase or decrease necessary to reflect the amount, if any, by which the rates and amount set under par. (a) for the current plan year differed from the rates and amount which would have equaled the amounts specified in sub. (1) (am) and (bm) in the current plan year.

SB466, s. 42 Section 42. 149.143 (2m) (a) (intro.) of the statutes is amended to read:

SB466,16,11 149.143 (2m) (a) (intro.) The department board shall keep a separate accounting of the difference between the following:

SB466, s. 43 Section 43. 149.143 (2m) (a) 2. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,16 149.143 (2m) (a) 2. The amount of premiums, including amounts received for premium, deductible, and prescription drug copayment subsidies, necessary to cover 60% 60 percent of the plan costs for the plan year.

SB466, s. 44 Section 44. 149.143 (2m) (b) 1. of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,16,23 149.143 (2m) (b) 1. To reduce premiums in succeeding plan years as provided in sub. (1) (am) 2. For eligible persons with coverage under s. 149.14 (2) (a), premiums may not be reduced below 140% 140 percent of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles cost-sharing provisions as are provided under the plan.

SB466, s. 45 Section 45. 149.143 (2m) (b) 2. of the statutes is amended to read:

SB466,17,2 149.143 (2m) (b) 2. For other needs of eligible persons, with the approval of the board including the purpose specified in s. 149.15 (4) (d).

SB466, s. 46 Section 46. 149.143 (2m) (b) 3. of the statutes is amended to read:

SB466,17,8 149.143 (2m) (b) 3. For distribution to eligible persons, notwithstanding any requirements in this chapter related to setting premium amounts. The department board, with the approval of the board and the concurrence of the plan actuary, shall determine the policies, eligibility criteria, methodology, and other factors to be used in making any distribution under this subdivision.

SB466, s. 47 Section 47. 149.143 (2m) (c) of the statutes is created to read:

SB466,17,11 149.143 (2m) (c) The board shall consult with the department as necessary for the accounting under par. (a).

SB466, s. 48 Section 48. 149.143 (3) (a) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,17,24 149.143 (3) (a) If, during a plan year, the department board determines that the amounts estimated to be received as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the department board may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (bm) 1., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (bm) 2. and s. 149.142 (1) (b).

SB466, s. 49 Section 49 . 149.143 (3) (a) of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,18,13 149.143 (3) (a) If, during a plan year, the board determines that the amounts estimated to be received in manufacturer and labeler assessments and as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the board may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (bm) 1. 2m. a., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (bm) 2. 2m. b. and s. 149.142 (1) (b).

SB466, s. 50 Section 50. 149.143 (3) (b) of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,18,22 149.143 (3) (b) If the department board increases premium rates and insurer assessments and adjusts the provider payment rate under par. (a) and determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the department board may further adjust, in equal proportions, assessments set under sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard to sub. (1) (bm) but subject to s. 149.142 (1) (b).

SB466, s. 51 Section 51. 149.143 (4) of the statutes is amended to read:

SB466,19,3 149.143 (4) Using the procedure under s. 227.24, the department board may promulgate rules under sub. (2) or (3) for the period before the effective date of any permanent rules promulgated under sub. (2) or (3), but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the department board is not required to make a finding of emergency.

SB466, s. 52 Section 52. 149.143 (5) (a) of the statutes is amended to read:

SB466,19,13 149.143 (5) (a) Annually, no later than April 30, the department board shall perform a reconciliation with respect to plan costs, premiums, insurer assessments, and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the department board shall make any necessary adjustments in premiums, insurer assessments, or provider payment rates, subject to s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b). The board shall consult with the department as necessary in performing the reconciliation and in making the adjustments under this paragraph.

SB466, s. 53 Section 53 . 149.143 (5) (a) of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,19,24 149.143 (5) (a) Annually, no later than April 30, the board shall perform a reconciliation with respect to plan costs, premiums, insurer assessments, manufacturer and labeler assessments, and provider payment rate adjustments based on data from the previous calendar year. On the basis of the reconciliation, the board shall make any necessary adjustments in premiums, insurer assessments, or provider payment rates, subject to s. 149.142 (1) (b), for the fiscal year beginning on the first July 1 after the reconciliation, as provided in sub. (2) (b). The board shall consult with the department as necessary in performing the reconciliation and in making the adjustments under this paragraph.

SB466, s. 54 Section 54. 149.143 (5) (b) of the statutes is amended to read:

SB466,20,6 149.143 (5) (b) Except as provided in sub. (3) and s. 149.144, the department board shall adjust the provider payment rates to meet the providers' specified portion of the plan costs no more than once annually, subject to s. 149.142 (1) (b). The department board may not determine the adjustment on an individual provider basis or on the basis of provider type, but shall determine the adjustment for all providers in the aggregate, subject to s. 149.142 (1) (b).

SB466, s. 55 Section 55. 149.144 of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,20,18 149.144 Adjustments to insurer assessments and provider payment rates for premium, deductible, and prescription drug copayment reductions. The department board shall, by rule, adjust in equal proportions the amount of the assessment assessments set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to ss. 149.142 (1) (b) and 149.143 (1) (am), sufficient to reimburse the plan for premium reductions under s. 149.165 (2) and (3), deductible reductions under s. 149.14 (5) (a), and any prescription drug copayment reductions under s. 149.14 (5) (e). The department board shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.

SB466, s. 56 Section 56. 149.145 of the statutes, as affected by 2003 Wisconsin Act 33, is amended to read:

SB466,21,8 149.145 Program budget. The department, in consultation with the board, shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in ss. 149.143 (1) and 149.144, including the methodologies specified in ss. 149.143, 149.144, and 149.146 for determining premium rates, insurer assessments, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (b), from the program budget the department board shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The department may not implement a program budget established under this section unless it is approved by the board shall consult with the department as necessary in deriving the actual provider payment rate.

SB466, s. 57 Section 57 . 149.145 of the statutes, as affected by 2003 Wisconsin Act .... (this act), is amended to read:

SB466,21,21 149.145 Program budget. The board shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.142 and in the most recent provider contracts that are in effect and on the funding sources specified in ss. 149.143 (1) and 149.144, including the methodologies specified in ss. 149.143, 149.144, and 149.146 for determining premium rates, insurer and manufacturer and labeler assessments, and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b) and subject to s. 149.142 (1) (b), from the program budget the board shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144. The board shall consult with the department as necessary in deriving the actual provider payment rate.

SB466, s. 58 Section 58. 149.146 (1) (b) of the statutes is amended to read:

SB466,22,6 149.146 (1) (b) An eligible person under par. (a) may elect once each year, at the time and according to procedures established by the department board, among the coverages offered under this section and s. 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 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 chapter and the person remained continuously covered under this chapter up to the time of electing the new coverage.