149.14(3)(e)
(e) Services of a licensed skilled nursing facility for eligible persons eligible for medicare, to the extent required by
s. 632.895 (3) and for not more than an aggregate 120 days during a calendar year, if the services are of the type which would qualify as reimbursable services under medicare. Coverage under this paragraph which is not required by
s. 632.895 (3) is subject to the deductible and coinsurance requirements under
sub. (5).
149.14(3)(g)
(g) Use of radium or other radioactive materials.
149.14(3)(k)
(k) Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
149.14(3)(m)
(m) Oral surgery for partially or completely unerupted, impacted teeth and oral surgery with respect to tissues of the mouth when not performed in connection with the extraction or repair of teeth.
149.14(3)(o)
(o) Transportation provided by a licensed ambulance service to the nearest facility qualified to treat the condition.
149.14(3)(p)
(p) For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by
s. 632.895 (3).
149.14(3)(r)
(r) Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.
149.14(4)
(4) Exclusions. Covered expenses for the coverage under this section shall not include the following:
149.14(4)(a)
(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.
149.14(4)(b)
(b) Care which is primarily for custodial or domiciliary purposes which do not qualify as eligible services under medicare.
149.14(4)(c)
(c) Any charge for confinement in a private room to the extent it is in excess of the institution's charge for its most common semiprivate room, unless a private room is prescribed as medically necessary by a physician. If the institution does not have semiprivate rooms, its most common semiprivate room charge shall be 90% of its lowest private room charge.
149.14(4)(d)
(d) That part of any charge for services or articles rendered or prescribed by a physician, dentist or other health care personnel which exceeds the prevailing charge in the locality where the service is provided or any charge not medically necessary.
149.14(4)(e)
(e) Any charge for services or articles the provision of which is not within the scope of authorized practice of the institution or individual providing the services or articles.
149.14(4)(f)
(f) Any expense incurred prior to the effective date of coverage under the plan for the person on whose behalf the expense is incurred.
149.14(4)(i)
(i) Routine physical examinations, including routine examinations to determine the need for eyeglasses and hearing aids.
149.14(4)(k)
(k) Services of blood donors and any fee for failure to replace the first 3 pints of blood provided to an eligible person each calendar year.
149.14(4)(L)
(L) Personal supplies or services provided by a hospital or nursing home, or any other nonmedical or nonprescribed supply or service.
149.14(4)(m)
(m) Experimental treatment, as determined by the department.
149.14(4m)
(4m) Payment is payment in full. Except for copayments, coinsurance or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under
ss. 149.143,
149.144 and
149.15 (3) (e) and may not bill an eligible person who receives the service or article for any amount by which the charge for the service or article is reduced under
s. 149.143,
149.144 or
149.15 (3) (e).
149.14(5)(a)(a) The plan shall offer a deductible in combination with appropriate premiums determined under this 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. 149.165. For eligible persons under
s. 149.165 (2) (a), the deductible shall be $500. For eligible persons under
s. 149.165 (2) (b), the deductible shall be $600. For eligible persons under
s. 149.165 (2) (c), the deductible shall be $700. For eligible persons under
s. 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.
149.14(5)(b)
(b) Except as provided in
par. (c), if the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage in a calendar year, the plan shall pay at least 80% of any additional covered costs incurred by the person during the calendar year.
149.14(5)(c)
(c) If the aggregate of the covered costs not paid by the plan under
par. (b) and the deductible exceeds $500 for an eligible person receiving medicare, $2,000 for any other eligible person during a calendar year or $4,000 for all eligible persons in a family, the plan shall pay 100% of all covered costs incurred by the eligible person during the calendar year after the payment ceilings under this paragraph are exceeded.
149.14(5)(d)
(d) Notwithstanding
pars. (a) to
(c), the 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 department under
s. 149.17 (4).
149.14(6)(a)(a) 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.
149.14(6)(b)1.1. In this paragraph, "eligible individual" means an individual for whom all of the following apply:
149.14(6)(b)1.a.
a. The aggregate of the individual's periods of creditable coverage is 18 months or more.
149.14(6)(b)1.b.
b. The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan or church plan, or under any health insurance offered in connection with any of those plans.
149.14(6)(b)1.c.
c. The individual does not have health insurance and is not eligible for coverage under a group health plan or a state plan under title XIX of the federal Social Security Act or any successor program.
149.14(6)(b)1.d.
d. The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.
149.14(6)(b)1.e.
e. If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.
149.14(6)(b)2.
2. An eligible individual who obtains coverage under the plan on or after June 17, 1998, may not be subject to any preexisting condition exclusion under the plan. An eligible individual who is covered under the plan on June 17, 1998, may not be subject to any preexisting condition exclusion on or after June 17, 1998.
149.14(7)(a)(a) Covered expenses under the plan shall not include any charge for care for injury or disease for which benefits are payable without regard to fault under coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance, for which benefits are payable under a worker's compensation or similar law, or for which benefits are payable under another policy of health care insurance, medicare, medical assistance or any other governmental program, except as otherwise provided by law.
149.14(7)(b)
(b) The 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.
149.14(7)(c)
(c) The 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.
149.143
149.143
Payment of plan costs. 149.143(1)
(1) The department shall pay or recover the operating and administrative costs of the plan as follows:
149.143(1)(b)1.
1. A total of 60% from the following sources, calculated as follows:
149.143(1)(b)1.a.
a. First, from premiums from eligible persons with coverage under
s. 149.14 set at 150% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan, including amounts received for premium and deductible subsidies under
ss. 20.435 (5) (ah) and
149.144, and from premiums collected from eligible persons with coverage under
s. 149.146 set in accordance with
s. 149.146 (2) (b).
149.143(1)(b)1.c.
c. Third, by increasing premiums from eligible persons with coverage under
s. 149.14 to more than 150% but not more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan, including amounts received for premium and deductible subsidies under
ss. 20.435 (5) (ah) and
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
subd. 1. a. and
b. are insufficient to pay 60% of plan costs.
149.143(1)(b)1.d.
d. Fourth, notwithstanding
subd. 2., by increasing insurer assessments, excluding assessments under
s. 149.144, and adjusting provider payment rates, excluding adjustments to those rates under
ss. 149.144 and
149.15 (3) (e), in equal proportions and to the extent that the amounts under
subd. 1. a. to
c. are insufficient to pay 60% of plan costs.
149.143(2)(a)(a) Prior to each plan year, the department shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under
s. 149.165 and the deductible reductions under
s. 149.14 (5) (a) for the new plan year and do all of the following:
149.143(2)(a)1.a.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 and deductible subsidies under
ss. 20.435 (5) (ah) and
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% of the estimated plan costs for the new plan year, after deducting from the estimated plan costs the amount available in the appropriation under
s. 20.435 (5) (af) for that plan year.
149.143(2)(a)1.c.
c. If the amount estimated to be received under
subd. 1. a. is less than the amount estimated to be received under
subd. 1. b., direct the plan administrator to provide to the department, prior to the beginning of the plan year and according to procedures specified by the department, the amount of the difference. The department shall deposit all amounts received under this
subd. 1. c. in the appropriation account under
s. 20.435 (5) (gh).
149.143(2)(a)2.
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) (b) 1. a. and
c. and such that a rate for coverage under
s. 149.14 is not less than 150% nor more than 200% of the rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as are provided under the plan.
149.143(2)(a)3.
3. By rule 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) (b) 1. d. and
2. a. and notify the commissioner of the amount.
149.143(2)(a)4.
4. By the same rule as under
subd. 3. adjust the provider payment rate for the new plan year by estimating and setting the rate at the level necessary to equal the amounts specified in
sub. (1) (b) 1. d. and
2. b. and as provided in
s. 149.145.
149.143(2)(b)
(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 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) (b) in the current plan year.
149.143(3)(a)(a) If, during a plan year, the department 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 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) (b) 2. 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) (b) 2. b.
149.143(3)(b)
(b) If, after increasing premium rates and insurer assessments and adjusting the provider payment rate under
par. (a), the department 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 shall 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) (b) 2.
149.143(3m)
(3m) Subject to
s. 149.14 (4m), insurers and providers may recover in the normal course of their respective businesses without time limitation assessments or provider payment rate adjustments used to recoup any deficit incurred under the plan.
149.143(4)
(4) Using the procedure under
s. 227.24, the department 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 is not required to make a finding of emergency.
149.143 History
History: 1997 a. 27.
149.144
149.144
Adjustments to insurer assessments and provider payment rates for premium and deductible reductions. If the moneys under
s. 20.435 (5) (ah) are insufficient to reimburse the plan for premium reductions under
s. 149.165 and deductible reductions under
s. 149.14 (5) (a), or the department determines that the moneys under
s. 20.435 (5) (ah) will be insufficient to reimburse the plan for premium reductions under
s. 149.165 and deductible reductions under
s. 149.14 (5) (a), the department shall, by rule, adjust in equal proportions the amount of the assessment 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. 149.165 and deductible reductions under
s. 149.14 (5) (a). The department shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.
149.144 History
History: 1997 a. 27 ss.
4840c,
4845c.
149.145
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. 149.15 (3) (e) and in the most recent provider contracts that are in effect and on the funding sources specified in
s. 149.143 (1), 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), from the program budget the department 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.
149.145 History
History: 1997 a. 27.
149.146
149.146
Choice of coverage. 149.146(1)(a)(a) Beginning on January 1, 1998, in addition to the coverage required under
s. 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.
149.146(1)(b)2.
2. An eligible person may elect once each year, at the time and according to procedures established by the department, 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.
149.146(2)(a)(a) Except as specified by the department, the terms of coverage under
s. 149.14, including deductible reductions under
s. 149.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under
s. 149.165 do not apply to the coverage offered under this section.
