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.
149.146(2)(b)
(b) The schedule of premiums for coverage under this section shall be promulgated by rule by the 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. 149.14 by the same percentage as the percentage difference between the following:
149.146(2)(b)1.
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. 149.14.
149.146(2)(b)2.
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.
149.146 History
History: 1997 a. 27 ss.
4860c,
4860d; Stats. 1997 s. 149.146;
1997 a. 237.
149.15
149.15
Board of governors. 149.15(1)(1) The plan shall have a board of governors consisting of representatives of 2 participating insurers which are nonprofit corporations, representatives of 2 other participating insurers, 3 health care provider representatives, including one representative of the State Medical Society of Wisconsin, one representative of the Wisconsin Health and Hospital Association and one representative of an integrated multidisciplinary health system, and 3 public members, including one representative of small businesses in the state, appointed by the secretary for staggered 3-year terms. In addition, the commissioner, or a designated representative from the office of the commissioner, and the secretary, or a designated representative from the department, shall be members of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The secretary or the secretary's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative and the secretary or the secretary's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
149.15(2)
(2) Annually, the board shall make a report to the appropriate standing committees under
s. 13.172 (3) and to the members of the plan summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.
149.15(2m)
(2m) Annually, beginning in 1999, the board shall submit a report on or before June 30 to the legislature under
s. 13.172 (2) and to the governor on the operation of the plan, including any recommendations for changes to the plan.
149.15(3)
(3) The board shall do all of the following:
149.15(3)(a)
(a) Establish procedures under which applicants and participants may have grievances reviewed by an impartial body and reported to the board.
149.15(3)(c)
(c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established as provided under
s. 149.143. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice.
149.15(3)(d)
(d) Develop and implement a program to publicize the existence of the plan, the eligibility requirements and procedures for enrollment, and to maintain public awareness of the plan.
149.15(3)(e)
(e) Establish for payment of covered expenses, a payment rate that is 10% less than the charges approved by the plan administrator for reimbursement of covered expenses under
s. 149.14 (3).
149.15(4)
(4) The board may do any of the following:
149.15(4)(a)
(a) Prepare and distribute certificate of eligibility forms and enrollment instruction forms to insurance solicitors, agents and brokers, and to the general public in this state.
149.15(4)(b)
(b) Provide for reinsurance of risks incurred by the plan, and may enter into reinsurance agreements with insurers to establish a reinsurance plan for risks of coverage described in the plan, or obtain commercial reinsurance to reduce the risk of loss through the pool.
149.15(5)
(5) The department may, by rule, establish additional powers and duties of the board.
149.15(6)
(6) If any provision of this chapter conflicts with
s. 625.11 or
625.12, this chapter prevails.
149.15(7)(a)(a) The board is not liable for any obligation of the plan.
149.16
149.16
Plan administrator. 149.16(3)(a)(a) The plan administrator shall perform all eligibility and administrative claims payment functions relating to the plan.
149.16(3)(b)
(b) The plan administrator shall establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the department.
149.16(3)(c)
(c) The plan administrator shall perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
149.16(3)(c)1.
1. Making available information relating to the proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made.
149.16(3)(c)2.
2. Evaluating the eligibility of each claim for payment under the plan.
149.16(3)(c)3.
3. Notifying each claimant within 30 days after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected or compromised.
149.16(3)(e)
(e) The plan administrator, under the direction of the department, shall pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the plan administrator's payments for claims expenses exceed premium payments, the board shall forward to the department, and the department shall provide to the plan administrator, additional funds for payment of claims expenses.
149.16 History
History: 1997 a. 27 ss.
3030,
3031,
4882 to
4884c,
4886.
149.165
149.165
Reductions in premiums for low-income eligible persons. 149.165(2)
(2) If the household income, as defined in
s. 71.52 (5) and as determined under
sub. (3), of an eligible person is equal to or greater than the first amount and less than the 2nd amount listed in any of the following, the department shall reduce the premium for the eligible person to the rate shown after the amounts:
