Amendment SSA1-AB416

AB416-SSA1,9,10 1. Premiums received for health care coverage.

AB416-SSA1,9,11 2. Subscriber contract charges received for health care coverage.

AB416-SSA1,9,13 3. Health maintenance organization, limited service health organization or preferred provider plan charges received for health care coverage.

AB416-SSA1,9,15 4. The sum of benefits paid and administrative costs incurred for health care coverage under a medical reimbursement plan.

AB416-SSA1,9,17 (b) This subsection does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 29 Section 29 . 619.13 of the statutes is repealed and recreated to read:

AB416-SSA1,9,23 619.13 Health care surcharges. (1) (a) Except as provided in sub. (2), to cover claims paid under the plan and the operating and administrative expenses of the plan, every health care provider shall impose and collect on every charge billed by the health care provider a surcharge in an amount set by the board under s. 619.15 (3) (bm) or (4) (c).

AB416-SSA1,9,25 (am) Each individual or insurer or other 3rd-party payer subject to the surcharge under par. (a) shall pay the surcharge to the health care provider.

AB416-SSA1,10,11 (b) A health care provider may retain up to 15% of the surcharge amounts under par. (a) that are collected before July 1, 1997, for its own administrative expenses. The board shall establish by rule the amount that a health care provider may retain of surcharges collected on and after July 1, 1997, for its administrative expenses at a level sufficient to cover the health care provider's administrative expenses. The health care provider shall remit the remainder of the surcharge amounts collected, after deducting its administrative expenses, to the board on a quarterly basis, on or before the last day of the next month following the end of each calendar quarter, along with a report that identifies any insurer or other 3rd-party payer that has failed to pay a significant surcharge amount billed during that calendar quarter.

AB416-SSA1,10,12 (2) Subsection (1) does not apply to any of the following:

AB416-SSA1,10,13 (a) Charges billed for services or articles provided to any of the following:

AB416-SSA1,10,14 1. Medical assistance recipients.

AB416-SSA1,10,16 2. Persons receiving relief under s. 49.025, 49.027 or 49.029 or under a county-funded relief program under s. 59.07 (154).

AB416-SSA1,10,18 3. Persons with coverage under the plan, including an alternative plan under s. 619.145.

AB416-SSA1,10,20 4. Persons with coverage under part A or part B of Title XVIII of the federal social security act, 42 USC 1395 to 1395zz.

AB416-SSA1,10,22 5. Persons for whom health care benefits are provided under any other federal assistance program.

AB416-SSA1,10,23 (b) Charges payable by worker's compensation insurance.

AB416-SSA1,11,2 (3) An insurer or other 3rd-party payer that pays a charge for a service or article on behalf of the person receiving the service or article shall include a line item identifying payment of the surcharge on any documentation of payment provided to the health care provider providing the service or article.

AB416-SSA1,11,7 (4) The surcharge under this section shall be imposed and paid in addition to the charge for a service or article, including fees and payments for fees specified in existing contracts unless such a contract specifically provides that the fees or payments for fees specified in the contract include any surcharge that may be imposed in addition to the amount charged for a service or article.

AB416-SSA1,11,14 (4m) If the person receiving the service or article, rather than an insurer or other 3rd-party payer, is paying for the service or article directly and full payment is not made in one payment, any instalment payments received by the health care provider shall be credited against the balance due on the charge for the service or article first and credited against the balance due on the surcharge only after the charge for the service or article is paid in full. This subsection does not apply if the payer specifies that a payment is intended to cover the surcharge.

AB416-SSA1,11,18 (5) A health care provider is not liable for the payment of any surcharge amount imposed but not collected by the health care provider. A health care provider is immune from civil liability for imposing, collecting or attempting to collect a surcharge under this section.

AB416-SSA1,11,21 (6) (a) If the surcharge under this section or its application is held by a court to be invalid with respect to any person or group of persons, then the surcharge or its application shall be invalid with respect to all persons.

AB416-SSA1,12,2 (b) If the commissioner, after consulting with the attorney general, determines that the surcharge or its application is invalid under par. (a) with respect to all persons, the commissioner shall certify such determination to the revisor of statutes. Upon the certification, the revisor of statutes shall publish notice in the Wisconsin administrative register of the determination, the date of the certification and that on the date of the certification:

AB416-SSA1,12,3 1. All of the following are effective:

AB416-SSA1,12,4 a. Section 619.10 (3m), 1993 stats., for 2 years.

AB416-SSA1,12,5 b. Section 619.13, 1993 stats., for 2 years.

AB416-SSA1,12,6 c. Section 619.135 (2) and (3), 1993 stats., for 2 years.

AB416-SSA1,12,7 d. Section 619.145 (3) (e) and (4), 1993 stats., for 2 years.

AB416-SSA1,12,8 e. Section 619.15 (3) (c) and (4) (c) and (e), 1993 stats., for 2 years.

AB416-SSA1,12,9 f. Section 619.175, 1993 stats., for 2 years.

AB416-SSA1,12,10 2. All of the following are not effective:

AB416-SSA1,12,11 a. Section 619.10 (3m), 1995 stats.

AB416-SSA1,12,12 b. Section 619.13, 1995 stats.

AB416-SSA1,12,13 c. Section 619.135 (2) and (3), 1995 stats.

AB416-SSA1,12,14 d. Section 619.15 (3) (bc), (bm) and (c) and (4) (c), 1995 stats.

AB416-SSA1,12,15 e. Section 619.175, 1995 stats.

AB416-SSA1,12,16 (7) This section does not apply after June 30, 2000.

AB416-SSA1, s. 30 Section 30 . 619.13 of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

AB416-SSA1,12,22 619.13 Participation of insurers. (1) (a) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under par. (b) would be so minimal as to not exceed the estimated cost of levying the assessment.

AB416-SSA1,13,3 (b) Except as provided by a rule promulgated under s. 619.145 (4), every participating insurer shall share in the operating, administrative and subsidy expenses of the plan in proportion to the ratio of the insurer's total health care coverage revenue for residents of this state during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers for residents of this state during the preceding calendar year, as determined by the commissioner.

AB416-SSA1,13,9 (c) If assessments and other receipts by the commissioner, board or administering carrier exceed payments made to alternative plans in accordance with contracts entered into under s. 619.145 (3) and the actual losses and administrative expenses of the plan, the excess shall be held at interest and used by the board to offset future losses or to reduce plan premiums. In this paragraph, "future losses" includes reserves for incurred but not reported claims.

AB416-SSA1,13,12 (d) 1. Each insurer's proportion of participation under par. (b) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner.

AB416-SSA1,13,18 2. If the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the commissioner or the board to carry out the commissioner's or the board's responsibilities under this subchapter, the commissioner may promulgate rules requiring insurers to report the information necessary for the commissioner and the board to make the determinations required under this subchapter.

AB416-SSA1,13,22 (2) Any deficit incurred under the plan shall be recouped by assessments apportioned under sub. (1) by the board among participating insurers, who may recover these amounts in the normal course of their respective businesses without time limitation.

AB416-SSA1,13,24 (3) This section does not apply after 2 years after the effective date of this subsection .... [revisor inserts date].

AB416-SSA1, s. 31 Section 31 . 619.135 (2) of the statutes is amended to read:

AB416-SSA1,14,9 619.135 (2) If the moneys under s. 20.145 (7) (a) and (g) are insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), or the commissioner determines that the moneys under s. 20.145 (7) (a) and (g) will be insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), the commissioner shall, by rule, increase the amount of the assessment under sub. (1) (a) or levy an assessment against every insurer, or a combination of both, sufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a).

AB416-SSA1, s. 32 Section 32 . 619.135 (2) of the statutes, as affected by 1995 Wisconsin Act .... (this act), section 31, is repealed and recreated to read:

AB416-SSA1,14,20 619.135 (2) If the moneys under s. 20.145 (7) (a) and (g) are insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), or the commissioner determines that the moneys under s. 20.145 (7) (a) and (g) will be insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), the commissioner shall, by rule, increase the amount of the assessment under sub. (1) (a) or levy an assessment against every insurer, or a combination of both, sufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a).

AB416-SSA1, s. 33 Section 33 . 619.135 (2) of the statutes, as affected by 1995 Wisconsin Act .... (this act), sections 31 and 32, is repealed and recreated to read:

AB416-SSA1,15,5 619.135 (2) If the moneys under s. 20.145 (7) (a) and (g) are insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), or the commissioner determines that the moneys under s. 20.145 (7) (a) and (g) will be insufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a), the commissioner shall, by rule, increase the amount of the assessment under sub. (1) (a) sufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a).

AB416-SSA1, s. 34 Section 34 . 619.135 (3) of the statutes is amended to read:

AB416-SSA1,15,12 619.135 (3) In addition to the assessments assessment under subs. sub. (1) (a) and (2), the commissioner may, by rule, establish an assessment to be levied against each insurer that issues a notice of rejection under s. 619.12 (1) (a) to a person who becomes eligible for and obtains coverage under the plan as a result of receiving the notice. Any assessments levied and collected under this subsection shall be credited to the appropriation under s. 20.145 (7) (g).

AB416-SSA1, s. 35 Section 35 . 619.135 (3) of the statutes, as affected by 1995 Wisconsin Act .... (this act), section 34, is repealed and recreated to read:

AB416-SSA1,15,20 619.135 (3) In addition to the assessments under subs. (1) (a) and (2), the commissioner may, by rule, establish an assessment to be levied against each insurer that issues a notice of rejection under s. 619.12 (1) (a) to a person who becomes eligible for and obtains coverage under the plan as a result of receiving the notice. Any assessments levied and collected under this subsection shall be credited to the appropriation under s. 20.145 (7) (g).

AB416-SSA1, s. 36 Section 36 . 619.135 (3) of the statutes, as affected by 1995 Wisconsin Act .... (this act), sections 33 and 34, is repealed and recreated to read:

AB416-SSA1,16,3 619.135 (3) In addition to the assessment under sub. (1) (a), the commissioner may, by rule, establish an assessment to be levied against each insurer that issues a notice of rejection under s. 619.12 (1) (a) to a person who becomes eligible for and obtains coverage under the plan as a result of receiving the notice. Any assessments levied and collected under this subsection shall be credited to the appropriation under s. 20.145 (7) (g).

AB416-SSA1, s. 37 Section 37. 619.14 (5) (a) of the statutes is amended to read:

AB416-SSA1,16,25 619.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter 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. 619.165. For eligible persons under s. 619.165 (1) (b) 1., the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2., the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3., the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4., 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. The schedule of premiums shall be promulgated by rule by the commissioner , subject to s. 619.15 (3) (f). The commissioner shall set rates at 60% of the operating and administrative costs of the plan premiums for eligible persons who have a household income, as defined in s. 71.52 (5) and as determined under s. 619.165 (1) (d), at or above the threshold amount established under s. 619.15 (3) (g) at a higher rate than premiums for eligible persons who have a household income below the threshold amount.

AB416-SSA1, s. 38 Section 38. 619.14 (5) (d) of the statutes is amended to read:

AB416-SSA1,17,8 619.14 (5) (d) Notwithstanding pars. (a) to (c), the 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 commissioner under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 or who are unable to enroll in an alternative plan because of the unavailability of such a plan in the individual's geographic area.

AB416-SSA1, s. 39 Section 39. 619.145 (1) of the statutes is amended to read:

AB416-SSA1,17,16 619.145 (1) The Except as provided in sub. (1m), the board may offer to persons eligible for coverage under s. 619.12 the opportunity to enroll, on a voluntary basis, in an alternative plan that uses managed care and that the commissioner determines provides benefits that are substantially equivalent to or greater than the benefits provided under the plan. A person who voluntarily enrolls in an alternative plan under this section is ineligible for coverage under the plan for 12 months after enrolling in the alternative plan.

AB416-SSA1, s. 40 Section 40. 619.145 (1m) of the statutes is created to read:

AB416-SSA1,17,22 619.145 (1m) (a) The board shall promulgate rules that implement the use of alternative plans that use managed care and capitation or other risk-sharing mechanisms and that the commissioner determines provide benefits for persons who use the services of providers designated by the alternative plan that are substantially equivalent to or greater than the benefits provided under the plan.

AB416-SSA1,17,25 (b) Beginning on July 1, 1997, the board shall offer to persons eligible for coverage under s. 619.12 the opportunity to enroll, and may require such persons to enroll, in an alternative plan.

AB416-SSA1,18,7 (c) Notwithstanding s. 619.14 (5) (a), the board may by rule establish premiums for persons who enroll in an alternative plan that are different from premiums for persons who do not enroll in an alternative plan to reflect the differences in the cost of covered services and articles. A person who is unable to enroll in an alternative plan because of the unavailability of such a plan in the person's geographic area, however, shall be allowed to pay the same premium rate as persons who do enroll in an alternative plan.

AB416-SSA1, s. 41 Section 41. 619.145 (3) (e) of the statutes is repealed.

AB416-SSA1, s. 42 Section 42. 619.145 (3) (e) of the statutes is created to read:

AB416-SSA1,18,13 619.145 (3) (e) Subject to sub. (4), a reduction in the alternative plan's assessment under s. 619.13 for operating and administrative, but not subsidy, expenses of the plan. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 43 Section 43. 619.145 (4) of the statutes is repealed.

AB416-SSA1, s. 44 Section 44. 619.145 (4) of the statutes is created to read:

AB416-SSA1,18,19 619.145 (4) A contract under sub. (3) may not provide for a reduction in the assessment under s. 619.13 against an alternative plan unless the assessment reduction has been adopted by rule under s. 619.15 (4) (e). This subsection does not apply after 2 years after the effective date of this subsection .... [revisor inserts date].

AB416-SSA1, s. 45 Section 45. 619.15 (1) of the statutes is amended to read:

AB416-SSA1,19,8 619.15 (1) The plan shall operate subject to the supervision and approval of a board consisting of representatives of 2 participating insurers which are nonprofit corporations, 2 other participating insurers 3 insurers and 3 health care providers, and 3 public members, appointed by the commissioner for staggered 3-year terms. In addition, the commissioner or a designated representative from the office of the commissioner shall be a member 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 commissioner or the commissioner's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.

AB416-SSA1, s. 46 Section 46. 619.15 (3) (bc) of the statutes is created to read:

AB416-SSA1,19,13 619.15 (3) (bc) Specify all persons that are required to impose and collect the surcharge under s. 619.13 (1) (a). The board shall include every type of provider that may provide a covered service or article under s. 619.14 (3). This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 47 Section 47. 619.15 (3) (bc) of the statutes, as created by 1995 Wisconsin Act .... (this act), is repealed.

AB416-SSA1, s. 48 Section 48. 619.15 (3) (bm) of the statutes is created to read:

AB416-SSA1,19,23 619.15 (3) (bm) Set the amount of the surcharge under s. 619.13 (1) (a) at a level that is sufficient to cover claims paid under the plan, the operating and administrative expenses of the plan and the administrative expenses that may be retained by health care providers under s. 619.13 (1) (b) at a level sufficient to cover a health care provider's administrative expenses. The amount shall be a flat encounter fee, and the board may provide for different surcharge amounts for different services or articles. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 49 Section 49. 619.15 (3) (bm) of the statutes, as created by 1995 Wisconsin Act .... (this act), is repealed.

AB416-SSA1, s. 50 Section 50. 619.15 (3) (c) of the statutes is amended to read:

AB416-SSA1,20,10 619.15 (3) (c) Collect assessments surcharges from all insurers health care providers 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 by the board. 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. The board shall ensure that all surcharges are deposited in the health insurance risk-sharing plan fund. This paragraph does not apply after June 30, 2000.

AB416-SSA1, s. 51 Section 51. 619.15 (3) (c) of the statutes, as affected by 1995 Wisconsin Act .... (this act), is repealed and recreated to read:

AB416-SSA1,20,20 619.15 (3) (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 by the board. 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. This paragraph does not apply after 2 years after the effective date of this paragraph .... [revisor inserts date].

AB416-SSA1, s. 52 Section 52. 619.15 (3) (f) and (g) of the statutes are created to read:

AB416-SSA1,20,24 619.15 (3) (f) Determine the percentage, but not less than 60%, of the operating and administrative costs of the plan at which the commissioner must set premium rates under s. 619.14 (5) (a).

AB416-SSA1,21,3 (g) Establish a threshold amount for the household income, as defined in s. 71.52 (5) and as determined under s. 619.165 (1) (d), of an eligible person for purposes of determining premium rates under s. 619.14 (5) (a).

AB416-SSA1, s. 53 Section 53 . 619.15 (4) (c) of the statutes is repealed and recreated to read: