27,3026f
Section 3026f. 149.143 of the statutes is created to read:
149.143 Payment of plan costs.
(1) The department shall pay or recover the operating and administrative costs of the plan as follows:
(a) First from the appropriation under s. 20.435 (5) (af).
(b) The remainder of the costs as follows:
1. A total of 60% from the following sources, calculated as follows:
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).
b. Second, from the appropriation under s. 20.435 (5) (gh), to the extent that the amounts under subd. 1. a. are insufficient to pay 60% of plan costs.
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.
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.
2. A total of 40% as follows:
a. Fifty percent from insurer assessments, excluding assessments under s. 149.144.
b. Fifty percent from adjustments to provider payment rates, excluding adjustments to those rates under ss. 149.144 and 149.15 (3) (e).
(2) (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:
1. 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.
b. Estimate the amount of enrollee premiums that will be received under sub. (1) (b) 1. a.
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).
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.
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.
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.
(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.
(3) (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.
(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.
(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.
(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.
(5) Notwithstanding sub. (2) (a) (intro.), the department shall set premium rates, insurer assessments and provider payment rates for the period beginning on January 1, 1998, and ending on June 30, 1998, in the manner provided in subs. (1), (2) (a), (3) and (4). This subsection applies to policies in effect on January 1, 1998, as well as to policies issued or renewed on or after January 1, 1998.
27,3026p
Section 3026p. 149.145 of the statutes is created to read:
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.
27,3027m
Section 3027m. 149.15 (2m) of the statutes is created to read:
149.15 (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.
27,3027r
Section 3027r. 149.15 (3) (f) of the statutes is created to read:
149.15 (3) (f) Advise the department on the choice of coverage under s. 149.146.
27,3030
Section 3030
. 149.16 (title) of the statutes is created to read:
149.16 (title) Plan administrator.
27,3031
Section 3031
. 149.16 (1) of the statutes is created to read:
149.16 (1) The fiscal agent under s. 49.45 (2) (b) 2. shall administer the plan.
27,3031m
Section 3031m. 149.20 of the statutes is created to read:
149.20 Rule-making in consultation with board. In promulgating any rules under this chapter, the department shall consult with the board.
27,3033
Section 3033
. 150.21 (1) of the statutes is amended to read:
150.21 (1) The construction or total replacement of a new nursing home.
27,3034
Section 3034
. 150.21 (3) of the statutes is amended to read:
150.21 (3) A capital expenditure, other than a renovation or replacement, that exceeds $1,000,000 by or on behalf of a nursing home.
27,3035
Section 3035
. 150.21 (4) of the statutes is amended to read:
150.21 (4) An expenditure, other than a renovation or replacement, that exceeds $600,000 for clinical equipment by or on behalf of a nursing home.
27,3036
Section 3036
. 150.31 (5t) of the statutes is created to read:
150.31 (5t) The department shall decrease the statewide bed limits specified in sub. (1) to account for any reduction in the licensed bed capacity of a nursing home that has relinquished use of a bed, as specified in s. 49.45 (6m) (ap) 4.
27,3037
Section 3037
. 150.35 (3m) (a) 3. of the statutes is amended to read:
150.35 (3m) (a) 3. All applications for activities that are specified in s. 150.21 (3), that are renovations with capital expenditures which do not exceed $1,500,000 and that do not include additions, the replacement of a nursing home or an increase in the bed capacity of a nursing home.
27,3038
Section 3038
. 150.39 (2) of the statutes is amended to read:
150.39 (2) The cost of renovating or providing an equal number of nursing home beds or of an equal expansion would be consistent with the cost at similar nursing homes, and the applicant's per diem rates would be consistent with those of similar nursing homes.
27,3041
Section 3041
. 153.01 (4) of the statutes is created to read:
153.01 (4) “Department" means the department of health and family services.
27,3042
Section 3042
. 153.01 (4m) of the statutes is repealed.
27,3043
Section 3043
. 153.01 (6) of the statutes is repealed.
27,3044
Section 3044
. 153.05 (1) (c) 1. of the statutes is amended to read:
153.05 (1) (c) 1. Identification of charges in each hospital's most recent entire fiscal year for up to 100 charge elements, as selected by the office department, and identification of the increase or decrease in charges for each of these charge elements from amounts charged during the hospital's entire fiscal year that is nearest in time to the hospital's most recent entire fiscal year.
27,3045
Section 3045
. 153.05 (1) (e) of the statutes is amended to read:
153.05 (1) (e) Final audited financial statements of hospitals that include, for a hospital's most recent entire fiscal year, as dollar amounts, the amounts of revenue and expenditures for the hospital, in categories specified in rules promulgated by the commissioner department.
27,3046
Section 3046
. 153.05 (2) of the statutes is amended to read:
153.05 (2) The office department shall provide copies of reports published under ss. 153.10 to 153.35 at no charge to hospitals assessed under s. 153.60 (1) and, if assessed, at no charge to ambulatory surgery centers assessed under s. 153.60 (2). The office department shall provide copies of the reports to any person, upon the person's request, and the board shall advise the office
department as to whether the copies shall be provided at no charge or at a charge not to exceed the cost of printing, copying and mailing the report to the person.
27,3047
Section 3047
. 153.05 (3) of the statutes is amended to read:
153.05 (3) Upon request of the office department, state agencies shall provide health care information to the office department for use in preparing reports under ss. 153.10 to 153.35.
27,3048
Section 3048
. 153.05 (4) of the statutes is amended to read:
153.05 (4) (a) The office
department, under rules promulgated by the commissioner department, shall require hospitals to use, and private-pay patients and payers who are insurers to accept, uniform patient billing forms, shall require hospitals to submit to the office department the information provided on the billing forms, including, for an injury, the external cause of the event, and may require payers who are insurers to use a standard set of definitions for base data reporting under a uniform patient billing form.
(b) The office department, under rules promulgated by the commissioner department, may require ambulatory surgery centers to use uniform patient billing forms and other information, and, if so requiring, shall require ambulatory surgery centers to submit to the office
department the information provided on the billing forms, including, for an injury, the external cause of the event, using a standard set of definitions for base data reporting.
27,3049
Section 3049
. 153.05 (5) of the statutes is amended to read:
153.05 (5) The office department:
(a) Shall require hospitals to submit information regarding medical malpractice, staffing levels and patient case-mix, and expenditures related to labor relations consultants, as specified by the office department.
(b) May require hospitals to submit to the office
department information from sources identified under sub. (1) (a) to (e) that the office department deems necessary for the preparation of reports, plans and recommendations under ss. 153.10 to 153.35 and any other reports required of the office department in the form specified by the office department.
(bm) Shall require a hospital to submit to the office department information from sources identified under sub. (1) (e) by the date that is 4 months following the close of the hospital's fiscal year unless the office department grants an extension of time to file the information.
27,3050
Section 3050
. 153.05 (6) of the statutes is amended to read:
153.05 (6) If the requirements of s. 153.07 (2) are first met, the office department may contract with a public or private entity that is not a major purchaser, payer or provider of health care services in this state for the provision of data processing services for the collection, analysis and dissemination of health care information under sub. (1) or the department of health and family services shall provide the services under s. 153.07 (2).
27,3051
Section 3051
. 153.05 (6m) of the statutes is amended to read:
153.05 (6m) If the requirements of s. 153.07 (2) are first met, the office department may contract with the group insurance board for the provision of data collection and analysis services related to health maintenance organizations and insurance companies that provide health insurance for state employes or the commissioner
department shall provide the services under s. 153.07 (2). The office department shall establish contract fees for the provision of the services. All moneys collected under this subsection shall be credited to the appropriation under s. 20.145 (8) 20.435 (1) (kx).
27,3052
Section 3052
. 153.05 (7) of the statutes is amended to read:
153.05 (7) The office department may require each insurer authorized to write disability insurance to submit to the office department information obtained on uniform patient billing forms regarding reported claims for health care services which insureds who are residents of this state obtain in another state.
27,3053
Section 3053
. 153.05 (8) of the statutes is amended to read:
153.05 (8) Beginning April 1, 1992, the office department shall collect, analyze and disseminate, in language that is understandable to lay persons, health care information under the provisions of this chapter, as determined by rules promulgated by the commissioner
department, from health care providers, as defined by rules promulgated by the commissioner department, other than hospitals and ambulatory surgery centers. Data from physicians shall be obtained through sampling techniques in lieu of collection of data on all patient encounters and data collection procedures shall minimize unnecessary duplication and administrative burdens.
27,3054
Section 3054
. 153.05 (9) of the statutes is amended to read:
153.05 (9) The office department shall provide orientation and training to physicians, hospital personnel and other health care providers to explain the process of data collection and analysis and the procedures for data verification, interpretation and release.
27,3055
Section 3055
. 153.05 (11) of the statutes is amended to read:
153.05 (11) In order to elicit public comment concerning the reports required under ss. 153.10 to 153.35, the office department shall, following the release of the reports and by a date that is determined by the board, provide notice of and hold public hearings.
27,3056
Section 3056
. 153.05 (12) of the statutes is amended to read:
153.05 (12) The office department shall, to the extent possible and upon request, assist members of the public in interpreting data in health care information disseminated by the office department.
27,3057
Section 3057
. 153.07 (1) of the statutes is amended to read:
153.07 (1) The board shall advise the director of the office department with regard to the collection, analysis and dissemination of health care information required by this chapter.
27,3058
Section 3058
. 153.07 (2) of the statutes is amended to read:
153.07 (2) The board, upon advice of the office department, shall first determine whether to contract for services pursuant to s. 153.05 (6) or (6m). If the board determines to contract for such services, it shall approve specifications for a contract including the length of the contract and the standards for determining potential contractor conflicts with the purposes of the office
department as specified under s. 153.05 (1). In the alternative, the board may direct the office to have the department of health and family services department to provide the services under s. 153.05 (6) or (6m). The board may subsequently determine to contract for these services in subsequent years. If the board decides to bid the contract for services under s. 153.05 (6) or (6m), the department of health and family services may offer a bid as would any other potential contractor. The board shall evaluate a contractor's performance 6 months prior to the close of each existing contract.
27,3059
Section 3059
. 153.07 (3) of the statutes is amended to read:
153.07 (3) The board shall approve all rules which are proposed by the commissioner department for promulgation to implement this chapter.
