A medical care program of the federal Indian health service or of an American Indian tribal organization.
A health plan offered under chapter 89
of title 5 of the United States Code.
"Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191
"Eligible individual" means an individual for whom all of the following apply:
The aggregate of the individual's periods of creditable coverage is 18 months or more.
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.
The individual does not have creditable coverage and is not eligible for coverage under a group health plan, part A, part B, or part D of title XVIII of the federal Social Security Act or a state plan under title XIX of the federal Social Security Act or any successor program.
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.
If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, including under 2009 Wisconsin Act 11, section 9126 (2)
, the individual elected the continuation coverage.
The individual has exhausted any continuation coverage under par. (e)
"Eligible person" means a resident who qualifies under s. 149.12
whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.
"Federal continuation provision" means any of the following:
of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.
Part 6 of subtitle B of title I of the federal Employee Retirement Income Security Act of 1974, except for section 609 of that act.
"Federal governmental plan" means a benefit program established or maintained for its employees by the government of the United States or by any agency or instrumentality of the government of the United States.
"Governmental plan" has the meaning given under section 3 (32) of the federal Employee Retirement Income Security Act of 1974.
"Group health plan" means any of the following:
An employee welfare plan, as defined in section 3 (1) of the federal Employee Retirement Income Security Act of 1974, to the extent that the employee welfare plan provides medical care, including items and services paid for as medical care, to employees or to their dependents, as defined under the terms of the employee welfare plan, directly or through insurance, reimbursement, or otherwise.
Any program that would not otherwise be an employee welfare benefit plan and that is established or maintained by a partnership, to the extent that the program provides medical care, including items and services paid for as medical care, to present or former partners of the partnership or to their dependents, as defined under the terms of the program, directly or through insurance, reimbursement or otherwise.
"Health care coverage revenue" means any of the following, but does not include payments to health maintenance organizations under s. 49.45 (59) (a)
Subscriber contract charges received for health care coverage.
Health maintenance organization, limited service health organization or preferred provider plan charges received for health care coverage.
The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.
"Health insurance" means surgical, medical, hospital, major medical and other health service coverage provided on an expense-incurred basis and fixed indemnity policies. "Health insurance" does not include ancillary coverages such as income continuation, short-term, accident only, credit insurance, automobile medical payment coverage, coverage issued as a supplement to liability coverage, loss of time or accident benefits.
"HIV" means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.
Risk distributing arrangements providing for compensation of damages or loss through the provision of services or benefits in kind rather than indemnity in money.
Contracts of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction.
"Insurer" means any person or association of persons, including a health maintenance organization, limited service health organization or preferred provider plan offering or insuring health services on a prepaid basis, including, but not limited to, policies of health insurance issued by a currently licensed insurer, as defined in s. 600.03 (27)
, nonprofit hospital or medical service plans under ch. 613
, cooperative medical service plans under s. 185.981
, or other entity whose primary function is to provide diagnostic, therapeutic or preventive services to a defined population in return for a premium paid on a periodic basis. "Insurer" includes any person providing health services coverage for individuals on a self-insurance basis without the intervention of other entities, as well as any person providing health insurance coverage under a medical reimbursement plan to persons. "Insurer" does not include a plan under ch. 613
which offers only dental care.
"Medicare" means coverage under part A, part B, and part D of Title XVIII of the federal social security act, 42 USC 1395
et seq., as amended.
"Plan" means the health care insurance plan established and administered under subchapter II of this chapter.
"Policy" means any document other than a group certificate used to prescribe in writing the terms of an insurance contract, including endorsements and riders and service contracts issued by motor clubs.
"Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care or treatment related to the condition before that date.
"Premium" means any consideration for an insurance policy, and includes assessments, membership fees or other required contributions or consideration, however designated.
"Resident" means a person who has been legally domiciled in this state for a period of at least 3 months or, with respect to an eligible individual, an individual who resides in this state. For purposes of this chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability that prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state.
"State" means the same as in s. 990.01 (40)
except that it also includes the Panama Canal Zone.
No cause of action of any nature may arise against, and no liability may be imposed upon, the authority, plan, or board; or any agent, employee, or director of any of them; or participating insurers; or the commissioner; or any of the commissioner's agents, employees, or representatives, for any act or omission by any of them in the performance of their powers and duties under this chapter, unless the person asserting liability proves that the act or omission constitutes willful misconduct.
History: 2005 a. 74
HEALTH INSURANCE RISK-SHARING
Administration of plan. 149.11(1)
The authority shall be responsible for the operation of the plan and, subject to ss. 149.43 (2)
, may enter into contracts for the plan's administration.
The authority shall pay the operating and administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:
Moneys received from the federal government in high risk pool grants.
Any other moneys received by the authority from time to time.
The authority controls the assets of the fund.
Moneys in the fund may be expended only for the purposes specified in par. (a)
History: 1979 c. 313
; 1997 a. 27
; Stats. 1997 s. 149.11; 2005 a. 74
; 2007 a. 20
The federal Employee Retirement Income Security Act (ERISA) preempts any state law that relates to employee benefit plans. General Split Corp. v. Mitchell, 523 F. Supp. 427
Rules relating to creditable coverage.
The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a)
and that determine the creditable coverage to which s. 149.10 (2t) (b)
applies. The rules shall comply with section 2701 (c) of P.L. 104-191
Eligibility determination. 149.12(1)
Except as provided in subs. (1m)
, and (3)
, the authority 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 a positive, validated HIV test result, as defined in s. 252.01 (8)
; 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:
A notice of rejection of coverage from one or more insurers.
A notice of cancellation of coverage from one or more insurers.
A notice of reduction or limitation of coverage, including restrictive riders, from an insurer if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.
A notice of premium for a policy not yet in effect from 2 or more insurers which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.
The authority may not certify a person as eligible under circumstances requiring notice under sub. (1) (a)
if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in s. 633.01
Except as provided in subd. 2.
, no person who is covered under the plan and who voluntarily terminates the coverage under the plan is again eligible for coverage unless 12 months have elapsed since the person's latest voluntary termination of coverage under the plan.
2. Subdivision 1.
does not apply to any person who is an eligible individual or to any person who terminates coverage under the plan because he or she is eligible to receive medical assistance benefits.
No person on whose behalf the plan has paid out the lifetime limit under s. 149.14 (2) (a)
or more is eligible for coverage under the plan.
Except as provided in subd. 2.
, no person who is 65 years of age or older is eligible for coverage under the plan.
A person who has coverage under the plan on the date on which he or she attains the age of 65 years.