AB500: Bill Text

AB500, s. 36 Section 36. 49.45 (37) (intro.) of the statutes is amended to read:

AB500,16,6 49.45 (37) Plans of care. (intro.) The department may seek a waiver of the requirement under 42 USC 1396n (c) (1) that the department review and approve every written plan of care developed for each individual who receives, under 42 USC 1396n (c) (1), home or community-based services under ss. 49.46 (2) (b) 8. and 49.47 (6) (a) 1. The waiver of the requirement, if granted, shall apply to those county departments or private nonprofit agencies that administer the services and that the department finds and certifies have implemented effective quality assurance systems for service plan development and implementation. If the federal health care financing administration approves the department's request for waiver of the requirement, the department shall, in evaluating a quality assurance system for certification, consider all of the following:

AB500, s. 37 Section 37. 49.45 (50) of the statutes is created to read:

AB500,16,13 49.45 (50) Applicability. Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), subs. (2) (a) 9. to 14. and (b), (3) (b) to (k), (6b) to (9s), (13) to (16), (18), (20) to (22), (24) to (26), (29) to (32) and (35) to (37) do not apply with respect to persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2.

AB500, s. 38 Section 38. 49.46 (2) (a) (intro.) of the statutes is amended to read:

AB500,16,17 49.46 (2) (a) (intro.) Except as provided in par. pars. (be) and (bm), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following federally mandated benefits:

AB500, s. 39 Section 39. 49.46 (2) (b) (intro.) of the statutes is amended to read:

AB500,16,21 49.46 (2) (b) (intro.) Except as provided in par. pars. (be) and (bm), the department shall audit and pay allowable charges to certified providers for medical assistance on behalf of recipients for the following services:

AB500, s. 40 Section 40. 49.46 (2) (bm) of the statutes is created to read:

AB500,17,3 49.46 (2) (bm) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), benefits for an individual who is eligible for medical assistance under sub. (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) are limited to coverage under the basic plan under s. 637.05 or to the payment of medicare premiums, coinsurance and deductibles to the extent provided in pars. (c) and (cm).

AB500, s. 41 Section 41. 49.465 (10) of the statutes is created to read:

AB500,17,8 49.465 (10) This section does not apply on or after the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5) with respect to persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2.

AB500, s. 42 Section 42. 49.47 (6) (a) (intro.) of the statutes is renumbered 49.47 (6) (a) and amended to read:

AB500,17,14 49.47 (6) (a) The Except as provided in pars. (ag), (ar) and (as), the department shall audit and pay charges to certified providers for medical assistance services under s. 49.46 (2) (a) and (b) on behalf of the following: all medical assistance recipients eligible under sub. (4).

AB500, s. 43 Section 43. 49.47 (6) (a) 1. of the statutes is repealed.

AB500, s. 44 Section 44. 49.47 (6) (a) 6. of the statutes is renumbered 49.47 (6) (ag) and amended to read:

AB500,17,18 49.47 (6) (ag) 1. In this subdivision: 1) "entitled paragraph:

AB500,17,20 a. "Entitled to coverage under part A of medicare" means eligible for and enrolled in part A of medicare under 42 USC 1395c to 1395f; 2) "entitled.

AB500,17,22 b. "Entitled to coverage under part B of medicare" means eligible for and enrolled in part B of medicare under 42 USC 1395j to 1395L; and 3) "income.

AB500,17,24 c. "Income limitation" means income that is equal to or less than 100% of the poverty line, as established under 42 USC 9902 (2).

AB500,18,11 2. An For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare, meets the eligibility criteria under sub. (4) (a) and meets the income limitation, medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395zz which that are not paid under 42 USC 1395 to 1395zz, including those medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums payable under 42 USC 1395v; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare. Payment of coinsurance for a service under part B of medicare under 42 USC 1395j to 1395w may not exceed the allowable charge for the service under medical assistance minus the medicare payment.

AB500,18,19 3. An For an individual who is only entitled to coverage under part A of medicare, meets the eligibility criteria under sub. (4) (a) and meets the income limitation, medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395i which that are not paid under 42 USC 1395 to 1395i, including those medicare services that are not included in the approved state plan for services under 42 USC 1396; the monthly premiums, if applicable, under 42 USC 1395i-2 (d); and the late enrollment penalty, if applicable, for premiums under part A of medicare.

AB500,19,3 4. An For an individual who is entitled to coverage under part A of medicare, entitled to coverage under part B of medicare and meets the eligibility criteria for medical assistance under sub. (4) (a) but does not meet the income limitation, medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395zz which that are not paid under 42 USC 1395 to 1395zz, including those medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under part B of medicare under 42 USC 1395j to 1395w may not exceed the allowable charge for the service under medical assistance minus the medicare payment.

AB500,19,9 5. An For an individual who is only entitled to coverage under part A of medicare and meets the eligibility criteria for medical assistance under sub. (4) (a), but does not meet the income limitation, medical assistance shall pay the deductible and coinsurance portions of medicare services under 42 USC 1395 to 1395i, including those services that are not included in the approved state plan for services under 42 USC 1396.

AB500,19,17 6. For an individual who is only entitled to coverage under part B of medicare and meets the eligibility criteria under sub. (4), but does not meet the income limitation, medical assistance shall include payment of pay the deductible and coinsurance portions of medicare services under 42 USC 1395j to 1395w, including those medicare services that are not included in the approved state plan for services under 42 USC 1396. Payment of coinsurance for a service under part B of medicare may not exceed the allowable charge for the service under medical assistance minus the medicare payment.

AB500, s. 45 Section 45. 49.47 (6) (a) 6m. of the statutes is repealed.

AB500, s. 46 Section 46. 49.47 (6) (a) 7. of the statutes is renumbered 49.47 (6) (ar) and amended to read:

AB500,19,24 49.47 (6) (ar) Beneficiaries For medical assistance recipients who are eligible under sub. (4) (a) 2. or (am) 1., medical assistance shall pay for services under s. 49.46 (2) (a) and (b) that are related to pregnancy, including postpartum and family planning services, or related to other conditions which may complicate pregnancy.

AB500, s. 47 Section 47. 49.47 (6) (ag) 7. of the statutes is created to read:

AB500,20,5 49.47 (6) (ag) 7. For an individual who is entitled to coverage under part A of medicare, is entitled to coverage under part B of medicare and meets the eligibility criteria under sub. (4) (a) and whose income is greater than 100% of the poverty line but less than 120% of the poverty line, medical assistance shall pay the monthly premiums under 42 USC 1395r.

AB500, s. 48 Section 48. 49.47 (6) (as) of the statutes is created to read:

AB500,20,12 49.47 (6) (as) Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), benefits for an individual who is eligible for medical assistance under sub. (4) (a) 1. or 2. are limited to coverage under the basic plan under s. 637.05 or to the payment of medicare premiums, coinsurance and deductibles to the extent provided in pars. (ag) and (ar).

AB500, s. 49 Section 49. 49.47 (15) of the statutes is created to read:

AB500,20,18 49.47 (15) Applicability. Beginning on the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5), subs. (7) and (8) do not apply with respect to persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or sub. (4) (a) 1. or 2.

AB500, s. 50 Section 50. 49.475 (1) (a) of the statutes is amended to read:

AB500,20,22 49.475 (1) (a) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a), except that "disability insurance policy" does not include coverage under the basic plan under ch. 637.

AB500, s. 51 Section 51. 49.49 (7) of the statutes is created to read:

AB500,21,3 49.49 (7) Applicability. Subsections (3) to (4) do not apply with respect to offenses occurring on or after the first day of the 12th month beginning after the date on which the department makes a certification under s. 49.44 (5) with respect to persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2.

AB500, s. 52 Section 52. 613.03 (3) of the statutes is amended to read:

AB500,21,9 613.03 (3) Applicability of insurance laws. Except as otherwise specifically provided, service insurance corporations organized or operating under this chapter are subject to subch. II of ch. 619 and ss. 610.01, 610.11, 610.21, 610.23 and 610.24 and chs. 600, 601, 609, 617, 620, 623, 625, 627, 628, 631, 632, 635 , 637 and 645 and to no other insurance laws.

AB500, s. 53 Section 53. 625.12 (2) of the statutes is amended to read:

AB500,21,19 625.12 (2) Classification. Risks Subject to s. 637.25, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to s. ss. 632.365 and 637.25, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

AB500, s. 54 Section 54. 625.15 (1) of the statutes is amended to read:

AB500,22,4 625.15 (1) Rate making. An insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, subject to s. 632.365 if the rates are for motor vehicle liability insurance, subject to s. 632.365, or s. 637.25 if the rates are for coverage under the basic plan under ch. 637. In the alternative, the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

AB500, s. 55 Section 55. 625.22 (1) of the statutes is amended to read:

AB500,22,9 625.22 (1) Order in event of violation. If the commissioner finds after a hearing that a rate is not in compliance with s. 625.11 or 637.25, the commissioner shall order that its use be discontinued for any policy issued or renewed after a date specified in the order.

AB500, s. 56 Section 56. 628.34 (3) of the statutes is amended to read:

AB500,22,18 628.34 (3) Unfair discrimination. (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to s. ss. 632.365 and 637.25. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

AB500,22,24 (b) No insurer may refuse to insure or refuse to continue to insure, or limit the amount, extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage because of a mental or physical disability except when the refusal, limitation or rate differential is based on either sound actuarial principles supported by reliable data or actual or reasonably anticipated experience, subject to ss. 637.20, 637.23 and 637.25.

AB500, s. 57 Section 57. 628.36 (2) (b) 5. of the statutes is amended to read:

AB500,23,6 628.36 (2) (b) 5. Except for the small employer health insurance plan under subch. II of ch. 635 to the extent determined by the small employer insurance board under s. 635.23 (1) (b), and the basic plan under ch. 637 as determined by the commissioner under s. 637.05 (1), all health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans are subject to s. 632.87 (3).

AB500, s. 58 Section 58. 632.70 of the statutes is amended to read:

AB500,23,13 632.70 (title) Exemption for plan under ch. 635 or 637. The health insurance mandates, as defined in s. 601.423 (1), that are provided under this subchapter apply to the small employer health insurance plan under subch. II of ch. 635 only to the extent determined by the small employer insurance board under s. 635.23 (1) (b), and to the basic plan under ch. 637 only as determined by the commissioner under s. 637.05 (1).

AB500, s. 59 Section 59. 632.72 (1) of the statutes is renumbered 632.72 (1m).

AB500, s. 60 Section 60. 632.72 (1c) of the statutes is created to read:

AB500,23,17 632.72 (1c) In this section, "policy of health and disability insurance" does not include a policy issued under the basic plan under ch. 637.

AB500, s. 61 Section 61. 632.755 (2) of the statutes is renumbered 632.755 (2) (b).

AB500, s. 62 Section 62. 632.755 (2) (a) of the statutes is created to read:

AB500,23,21 632.755 (2) (a) In this subsection, "disability insurance policy" does not include coverage under the basic plan under ch. 637.

AB500, s. 63 Section 63. 635.01 of the statutes is renumbered 635.01 (1) and amended to read:

AB500,24,5 635.01 (1) This Except as provided in sub. (2), this subchapter applies to all group health insurance plans, policies or certificates, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer, and to individual health insurance policies, written on risks or operations in this state, providing coverage for employes of a small employer, or employes of a small employer and the employer when 3 or more are sold to a small employer.

AB500, s. 64 Section 64. 635.01 (2) of the statutes is created to read:

AB500,24,7 635.01 (2) This subchapter does not apply to the basic plan under ch. 637.

AB500, s. 65 Section 65. Chapter 637 of the statutes is created to read:

AB500,24,10 Chapter 637 Basic health insurance plan

AB500,24,12 637.01 Application. This chapter applies only if the department of health and social services makes a certification under s. 49.44 (5).

AB500,24,13 637.02 Definitions. In this chapter:

AB500,24,18 (1) "Abortion" means the use of any instrument, medicine, drug or any other substance or device with intent to terminate a pregnancy after implantation of a fertilized human ovum and with intent other than to increase the probability of a live birth, to preserve the life or health of the infant after live birth or to remove a dead fetus.

AB500,24,23 (2) "Community rate" means a uniform rate determined in such a manner that all insured individuals with the same level of coverage and plan design pay the same rate for that coverage, without regard to case characteristics or to loss or claim history, health condition, duration of coverage or other factors related to claims experience.

AB500,25,2 (3) "Dependent" means a spouse, an unmarried child under the age of 19 years, an unmarried child who is a full-time student under the age of 21 years and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and who is dependent upon the parent.

AB500,25,7 (4) "Employe" includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership, a member of a limited liability company and an independent contractor if the sole proprietor, business owner, partner, member or independent contractor is included as an employe under a health benefit plan of an employer.

AB500,25,8 (5) "Employer" means any of the following:

AB500,25,11 (a) An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business.

AB500,25,12 (b) The state.

AB500,25,13 (c) A municipality, as defined in s. 16.70 (8).

AB500,25,15 (6) "Medical assistance recipient" means a person entitled, under s. 49.44 (6), to coverage under the basic plan under s. 637.05.

AB500,25,17 (7) "Poverty line" means the poverty line as defined and revised annually under 42 USC 9902 (2).

AB500,25,19 (8) "Qualifying coverage" means benefits or coverage provided under any of the following:

AB500,25,20 (a) Medicare or medicaid.

AB500,25,22 (b) An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the basic plan.

AB500,26,2 (c) Except for a policy under the health insurance risk-sharing plan or an alternative plan under subch. II of ch. 619, an individual health insurance policy that provides benefits similar to or exceeding benefits provided under the basic plan if the policy has been in effect for at least one year.

AB500,26,8 637.05 Basic plan. (1) The commissioner shall by rule design a health care plan that provides basic coverage of hospital, surgical and medical services and items. The basic plan shall provide both single and family coverage. The commissioner shall require a copayment of at least $2 for every service or item covered under the basic plan. The commissioner may by rule exempt the basic plan from any health insurance mandate, as defined in s. 601.423 (1).

AB500,26,12 (2) The commissioner shall administer the basic plan under this chapter and may promulgate rules relating to the operation and administration of the basic plan, including rules that are designed to reduce adverse selection, or the effects of adverse selection, in relation to the basic plan.

AB500,26,16 (3) The commissioner shall ensure that individuals and employers may obtain, and that medical assistance recipients shall receive, coverage under the basic plan no later than the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5).

AB500,27,2 637.10 Designating regions; selecting insurers. (1) The commissioner may divide the state into regions for the purpose of pooling individuals and employes with coverage under the basic plan if the commissioner determines that regional pools will result in more efficient and cost-effective delivery of health care coverage or services. The commissioner shall select insurers to provide coverage under the basic plan using a competitive sealed proposal process. Any insurer authorized to do a health insurance business in this state may submit a proposal to provide coverage under a basic health insurance plan that complies with this chapter, any rules promulgated under this chapter and the terms of any waiver under s. 49.44 (2) or any legislation under s. 49.44 (3).

AB500,27,5 (2) An insurer selected by the commissioner shall comply with any requirements imposed by the commissioner related to the insurer's provision of coverage under the basic plan.

AB500,27,10 637.15 Coverage eligibility and entitlement. (1) Beginning on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5), persons eligible for medical assistance under s. 49.46 (1) (a) 1., 1m., 6. or 12., (c), (cg), (co), (cr) or (cs) or 49.47 (4) (a) 1. or 2. shall receive coverage, under s. 49.44 (6), under the basic plan.

AB500,27,14 (2) Beginning on the first day of the 12th month beginning after the date on which the department of health and social services makes a certification under s. 49.44 (5), all of the following are eligible to purchase coverage under the basic plan, subject to sub. (4):

AB500,27,15 (a) Any employer.