(2) Major medical expense coverage. 149.14(2)(a)(a)
The plan shall provide every eligible person who is not eligible for Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to deductible, copayment, and coinsurance payments, up to a lifetime limit per covered individual of $1,000,000 or a higher amount, as determined by the authority.
The plan shall provide an alternative policy for those persons eligible for medicare which reduces the benefits payable under par. (a)
by the amounts paid under medicare.
In addition to the coverage under pars. (a)
, the plan shall offer to all eligible persons who are not eligible for Medicare 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. An eligible person who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the authority, among the coverages offered under this paragraph and par. (a)
. 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 the plan. 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 the plan and the person remained continuously covered under the plan up to the time of electing the new coverage.
(3) Covered expenses.
Covered expenses for coverage under the plan shall be the payment rates established by the authority for services provided by persons licensed under ch. 446
and certified under s. 49.45 (2) (a) 11.
Covered expenses for coverage under the plan shall also be the payment rates established by the authority for, at a minimum, the following services and articles 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, except for prescription drugs that are provided by a network of pharmacies approved by the board, is provided by a provider certified under s. 49.45 (2) (a) 11.
Professional services for the diagnosis or treatment of injuries, illnesses, or conditions, other than mental or dental.
Subject to the limits under subd. 1.
, services for the chronically mentally ill in community support programs operated under s. 51.421
Drugs requiring a physician's prescription.
For persons eligible for Medicare, services of a licensed skilled nursing facility, 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 that would qualify as reimbursable services under Medicare. Coverage under this paragraph that is not required by s. 632.895 (3)
is subject to any deductible and coinsurance requirements provided by the authority.
For persons not eligible for medicare, services of a licensed skilled nursing facility, only to the extent required by s. 632.895 (3)
Use of radium or other radioactive materials.
Rental or purchase, as appropriate, of durable medical equipment or disposable medical supplies, other than eyeglasses and hearing aids.
Oral surgery for excision of partially or completely unerupted, impacted teeth and oral surgery with respect to the gums and other tissues of the mouth when not performed in connection with the extraction or repair of teeth.
Emergency and other medically necessary transportation provided by a licensed ambulance service to the nearest facility qualified to treat a covered condition.
Processing charges for blood including, but not limited to, the cost of collecting, testing, fractionating and distributing blood.
(3c) Temporary provider certification.
Notwithstanding the provider licensing and certification requirements under sub. (3) (intro.)
, for coverage of services or articles provided to an eligible person the authority may certify on a temporary basis a provider that is not licensed under ch. 446
but that is licensed in another state to provide the service or article, or a provider that is not certified under s. 49.45 (2) (a) 11.
The certification under this subsection may be retroactive.
(4) Plan design.
Subject to subs. (1)
, and (6)
, the authority shall establish the plan design, after taking into consideration the levels of health insurance coverage provided in the state and medical economic factors, as appropriate. Subject to subs. (1)
, and (6)
, the authority shall provide benefit levels, deductibles, copayment and coinsurance requirements, exclusions, and limitations under the plan that the authority determines generally reflect and are commensurate with comprehensive health insurance coverage offered in the private individual market in the state. The authority may develop additional benefit designs that are responsive to market conditions.
(5) Deductible and copayment subsidies. 149.14(5)(a)(a)
The authority shall establish and provide subsidies for deductibles paid by eligible persons with household incomes specified in s. 149.165 (2) (a)
The authority may provide subsidies for prescription drug copayment amounts paid by eligible persons specified in par. (a)
(6) Preexisting conditions.
An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan.
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.
The authority has a cause of action against an eligible participant for the recovery of the amount of benefits paid 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.
The authority 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.
Percentage of costs.
Except as provided in sub. (2)
, the authority shall set premium rates for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1)
In no event may plan premium rates exceed 200 percent of rates applicable to individual standard risks.
History: 2005 a. 74
Provider payment rates. 149.142(1)
Establishment of rates.
The authority shall establish provider payment rates for covered expenses that consist of the usual and customary payment rates, as determined by the authority, for the services and articles provided plus an adjustment determined by the authority. The adjustments to the usual and customary rates shall be sufficient to cover the portion of plan costs specified in s. 149.143 (1) (c)
and (2) (b)
(2m) 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 sub. (1)
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 sub. (1)
Payment of plan costs. 149.143(1)
Costs excluding subsidies.
The authority shall pay plan costs, excluding any premium, deductible, and copayment subsidies, first from any federal funds under s. 149.11 (2) (a) 3.
that exceed premium, deductible, and copayment subsidy costs in a policy year. The remainder of the plan costs, excluding premium, deductible, and copayment subsidy costs, shall be paid as follows:
Sixty percent from premiums paid by eligible persons.
(2) Subsidy costs.
The authority shall pay for premium, deductible, and copayment subsidies in a policy year first from any federal funds under s. 149.11 (2) (a) 3.
received in that year. The remainder of the subsidy costs shall be paid as follows:
Reductions in premiums for low-income eligible persons. 149.165(1)(1)
The authority shall reduce the premiums established under s. 149.141
for the eligible persons and in the manner set forth in subs. (2)
Subject to sub. (3m)
, 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 authority shall reduce the premium for the eligible person by the percentage of the premium shown after the amounts:
If equal to or greater than $0 and less than $10,000, by at least 30 percent.
If equal to or greater than $10,000 and less than $14,000, by at least 25 percent.
If equal to or greater than $14,000 and less than $17,000, by at least 20 percent.
If equal to or greater than $17,000 and less than $20,000, by at least 15 percent.
If equal to or greater than $20,000 and less than $25,000, by at least 10 percent.
Subject to par. (b)
, the authority shall establish and implement the method for determining the household income of an eligible person under sub. (2)
In determining household income under sub. (2)
, the authority shall consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:
The authority may approve adjustment of the household income dollar amounts listed in sub. (2) (a)
, except for the first dollar amount listed in sub. (2) (a)
, to reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
Contents of plan.
The plan shall include, but is not limited to, the following:
Subject to s. 149.143
, a rating plan calculated in accordance with generally accepted actuarial principles.
Procedures for applicants and participants to have grievances reviewed by an impartial body.
Chapters 600 to 645 applicable.
Except as otherwise provided in this subchapter, the plan shall comply and be administered in compliance with chs. 600
History: 1979 c. 313
; 1981 c. 314
; 1997 a. 27
; Stats. 1997 s. 149.18; 2005 a. 74
HEALTH INSURANCE RISK-SHARING
Creation and organization of authority. 149.41(1)(1)
There is created a public body corporate and politic to be known as the "Health Insurance Risk-Sharing Plan Authority." The board of directors of the authority shall consist of the commissioner of insurance, or his or her designee, as a nonvoting member, and the following members, who shall be nominated by the governor, and with the advice and consent of the senate appointed, for 3-year terms:
Four members who represent insurers participating in the plan.
Four members who represent health care providers, including one representative of the Wisconsin Medical Society, one representative of the Wisconsin Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin, and one representative of health care providers that provide services to persons with coverage under the plan.
Five other members, at least one of whom represents small businesses that purchase private health insurance, one of whom is a professional consumer advocate who is familiar with the plan, and at least 2 of whom are persons with coverage under the plan.
A vacancy on the board shall be filled in the same manner as the original appointment to the board for the remainder of the unexpired term, if any.
A member of the board may not be compensated for his or her services but shall be reimbursed for actual and necessary expenses, including travel expenses, incurred in the performance of his or her duties.
Annually, the governor shall appoint one member other than the commissioner as chairperson, and the members of the board may elect other officers as they consider appropriate. Seven voting members of the board constitute a quorum for the purpose of conducting the business and exercising the powers of the authority, notwithstanding the existence of any vacancy. The board may take action upon a vote of a majority of the members present, unless the bylaws of the authority require a larger number.
The board may appoint an executive director who shall not be a member of the board and who shall serve at the pleasure of the board. The authority may delegate by resolution to one or more of its members or its executive director any powers and duties that it considers proper. The executive director shall receive such compensation as may be determined by the board. The executive director or other person designated by resolution of the board shall keep a record of the proceedings of the authority and shall be custodian of all books, documents, and papers filed with the authority, the minute book or journal of the authority, and its official seal. The executive director or other person may cause copies to be made of all minutes and other records and documents of the authority and may give certificates under the official seal of the authority to the effect that such copies are true copies, and all persons dealing with the authority may rely upon such certificates.
History: 2005 a. 74
Duties of authority.
In addition to all other duties imposed under this chapter, the authority shall do all of the following:
Adopt policies for the administration of this chapter.