27,4818g
Section 4818g. 619.10 (3g) of the statutes is created to read:
619.10 (3g) “Governmental plan" has the meaning given under section 3 (32) of the federal Employee Retirement Income Security Act of 1974.
27,4818gm
Section 4818gm. 619.10 (3g) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3g).
27,4818j
Section 4818j. 619.10 (3j) of the statutes is created to read:
619.10 (3j) “Group health plan" means any of the following:
(a) An employe welfare plan, as defined in section 3 (1) of the federal Employee Retirement Security Act of 1974, to the extent that the employe welfare plan provides medical care, including items and services paid for as medical care, to employes or to their dependents, as defined under the terms of the employe welfare plan, directly or through insurance, reimbursement or otherwise.
(b) Any program that would not otherwise be an employe 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.
27,4818jm
Section 4818jm. 619.10 (3j) of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.10 (3j).
27,4819
Section 4819
. 619.10 (3m) and (4) of the statutes are renumbered 149.10 (3m) and (4).
27,4820
Section 4820
. 619.10 (4m) of the statutes is renumbered 149.10 (4m).
27,4821
Section 4821
. 619.10 (5) of the statutes is renumbered 149.10 (5) and amended to read:
149.10 (5) “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.
27,4822
Section 4822
. 619.10 (6) and (7) of the statutes are renumbered 149.10 (6) and (7).
27,4823
Section 4823
. 619.10 (8) of the statutes is renumbered 149.10 (8) and amended to read:
149.10 (8) “Plan" means the health care insurance plan established and administered under this
subchapter chapter.
27,4824
Section 4824
. 619.10 (9) of the statutes is renumbered 149.10 (9) and amended to read:
149.10 (9) “Resident" means a person who has been legally domiciled in this state for a period of at least 30 days or, with respect to an eligible individual, an individual who resides in this state. For purposes of this subchapter 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 which 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 for 30 days.
27,4825
Section 4825
. 619.11 of the statutes is renumbered 149.11 and amended to read:
149.11 (title) Establishment Operation of plan. The commissioner department shall promulgate rules establishing for the operation of a plan of health insurance coverage for an eligible person which satisfies the requirements of this chapter.
27,4825c
Section 4825c. 619.115 of the statutes is created to read:
619.115 Rules relating to creditable coverage. The commissioner shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 619.10 (2t) (a) and that determine the creditable coverage to which s. 619.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.
27,4825f
Section 4825f. 619.115 of the statutes, as created by 1997 Wisconsin Act .... (this act), is renumbered 149.115 and amended to read:
149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 619.10 149.10 (2t) (a) and that determine the creditable coverage to which s. 619.10 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.
27,4826
Section 4826
. 619.12 (title) of the statutes is renumbered 149.12 (title).
27,4827
Section 4827
. 619.12 (1) of the statutes is renumbered 149.12 (1), and 149.12 (1) (intro.), as renumbered, is amended to read:
149.12 (1) (intro.) Except as provided in subs. (1m) and (2), the board or administering carrier plan administrator 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 tested positive for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV, 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:
27,4828
Section 4828
. 619.12 (1m) (intro) and (a) of the statutes are consolidated, renumbered 149.12 (1m) and amended to read:
149.12 (1m) The board or administering carrier plan administrator may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by one of the following: (a) An an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.
27,4829
Section 4829
. 619.12 (1m) (b) of the statutes is repealed.
27,4830b
Section 4830b. 619.12 (2) (b) of the statutes is renumbered 149.12 (2) (b) and amended to read:
149.12 (2) (b) 1. 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 receiving, or is eligible to receive, medical assistance benefits.
27,4830c
Section 4830c. 619.12 (2) (c) of the statutes is renumbered 149.12 (2) (c) and amended to read:
149.12 (2) (c) No person on whose behalf the plan has paid out $500,000 $1,000,000 or more is eligible for coverage under the plan.
27,4830d
Section 4830d. 619.12 (2) (d) of the statutes is renumbered 149.12 (2) (d) and amended to read:
149.12 (2) (d) No Except for a person who is an eligible individual, no person who is 65 years of age or older is eligible for coverage under the plan.
27,4830ec
Section 4830ec. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (2) (e) and amended to read:
149.12 (2) (e) No person who is eligible for
health care benefits creditable coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are is provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
27,4830em
Section 4830em. 619.12 (2) (e) 1. of the statutes is renumbered 619.12 (2) (e) and amended to read:
619.12 (2) (e) Except as provided in subd. 2., no No person who is eligible for health care benefits, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that are provided by an employer on a self-insured basis or through health insurance is eligible for coverage under the plan.
27,4830f
Section 4830f. 619.12 (2) (e) 2. of the statutes is repealed.
27,4830g
Section 4830g. 619.12 (2) (e) 3. of the statutes is repealed.
27,4831
Section 4831
. 619.12 (3) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is renumbered 149.12 (3), and 149.12 (3) (c), as renumbered, is amended to read:
149.12 (3) (c) The commissioner, in consultation with the board, department may promulgate rules specifying other deductible or coinsurance amounts that, if paid or reimbursed for persons, will not make the persons ineligible for coverage under the plan.
27,4831c
Section 4831c. 619.12 (3) (a) of the statutes is amended to read:
619.12 (3) (a) Except as provided in pars. (b)
and to (c), no person is eligible for coverage under the plan for whom a premium, deductible or coinsurance amount is paid or reimbursed by a federal, state, county or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.
27,4831e
Section 4831e. 619.12 (3) (bm) of the statutes is created to read:
619.12 (3) (bm) Persons for whom premium costs for health insurance coverage are subsidized under s. 252.16 are not ineligible for coverage under the plan by reason of such payments.
27,4832b
Section 4832b. 619.123 of the statutes is repealed.
27,4833
Section 4833
. 619.125 of the statutes is renumbered 149.125 and amended to read:
149.125 Health insurance risk-sharing plan fund. There is created a health insurance risk-sharing plan fund, under the management of the board department, to fund administrative expenses.
27,4834
Section 4834
. 619.13 (title) of the statutes is renumbered 149.13 (title).
27,4835
Section 4835
. 619.13 (1) (a) of the statutes is renumbered 149.13 (1) and amended to read:
149.13 (1) 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) sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department of the insurers participating in the cost of administering the plan.
27,4836
Section 4836
. 619.13 (1) (b) of the statutes is renumbered 149.13 (2) and amended to read:
149.13 (2) Except as provided by a rule promulgated under s. 619.145 (4), every 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.
27,4837
Section 4837
. 619.13 (1) (c) of the statutes is repealed.
27,4838
Section 4838
. 619.13 (1) (d) of the statutes is renumbered 149.13 (3) and amended to read:
149.13 (3) (a) Each insurer's proportion of participation under par. (b) sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department under s. 149.143 (2) (a) 3.
(b) If the department or 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 department, the commissioner or the board to carry out the department's, commissioner's or the board's responsibilities under this subchapter chapter, the commissioner may shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and the board to make the determinations required under this subchapter chapter.
27,4839c
Section 4839c. 619.13 (2) of the statutes is repealed.
27,4840c
Section 4840c. 619.135 (title) of the statutes is renumbered 149.144 (title) and amended to read:
149.144 (title) Insurer
Adjustments to insurer assessments and provider payment rates for premium and deductible reductions.
27,4841c
Section 4841c. 619.135 (1) of the statutes is repealed.
27,4845c
Section 4845c. 619.135 (2) of the statutes is renumbered 149.144 and amended to read:
149.144 If the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah) are insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), or the commissioner department determines that the moneys under s. 20.145 (7) (a) and (g) 20.435 (5) (ah) will be insufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a), the commissioner department shall, by rule, increase adjust in equal proportions the amount of the assessment under sub. (1) (a) or levy an assessment against every insurer, or a combination of both, set under s. 149.143 (2) (a) 3. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to s. 149.143 (1) (b) 1., sufficient to reimburse the plan for premium reductions under s. 619.165 149.165 and deductible reductions under s. 619.14 149.14 (5) (a). The department shall notify the commissioner so that the commissioner may levy any increase in insurer assessments.
27,4846b
Section 4846b. 619.135 (3) of the statutes is repealed.
27,4847
Section 4847
. 619.14 (title) of the statutes is renumbered 149.14 (title).
27,4848
Section 4848
. 619.14 (1) of the statutes is renumbered 149.14 (1), and 149.14 (1) (b), as renumbered, is amended to read:
149.14 (1) (b) If an individual terminates medical assistance coverage and applies for coverage under the plan within 45 days after the termination and is subsequently found to be eligible under s. 619.12 149.12, the effective date of coverage for the eligible person under the plan shall be the date of termination of medical assistance coverage.
27,4849
Section 4849
. 619.14 (2) of the statutes is renumbered 149.14 (2), and 149.14 (2) (a), as renumbered, is amended to read:
149.14 (2) (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 sub. (3) and deductible and coinsurance payments authorized under sub. (5), up to a lifetime limit of $500,000
$1,000,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.
27,4850
Section 4850
. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14 (3) (intro.) and (c) 3., as renumbered, are amended to read:
149.14 (3) Covered expenses. (intro.) Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e) or by the department under s. 149.143 or 149.144, covered expenses for the coverage under this section shall be the usual and customary charges for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as restricted by cost containment provisions under s. 619.17 149.17 (4) and except as reduced by the board under s. 619.15 149.15 (3) (e)
or by the department under s. 149.143 or 149.144, covered expenses for the coverage under this section shall also be the usual and customary charges for the following services and articles when
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 is provided by a provider certified under s. 49.45 (2) (a) 11.:
(c) 3. Subject to the limits under subd. 2. and to rules promulgated by the commissioner department, services for the chronically mentally ill in community support programs operated under s. 51.421.
27,4851
Section 4851
. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14 (4) (intro.), (a) and (m), as renumbered, are amended to read:
149.14 (4) Exclusions. (intro.) Covered expenses for the coverage under this section shall not include the following:
(a) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect. Breast reconstruction of the affected tissue incident to a mastectomy shall not be considered treatment for cosmetic purposes.
(m) Experimental treatment, as determined by the board or its designee department.
27,4852c
Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title) and amended to read:
149.14 (5) (title) Premiums, deductibles Deductibles and coinsurance.
27,4853
Section 4853
. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and amended to read:
149.14 (5) (a) The plan shall offer a deductible in combination with appropriate premiums determined under this subchapter chapter 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. 619.165 149.165. For eligible persons under s. 619.165 (1) (b) 1. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4. 149.165 (2) (d), 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. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.
27,4854c
Section 4854c. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b).
27,4855c
Section 4855c. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c)
27,4856
Section 4856
. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and amended to read:
149.14 (5) (d) Notwithstanding pars. (a) to (c), the board department 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 department under s. 619.17 (4) (a) and for individuals who enroll in an alternative plan under s. 619.145 149.17 (4).
27,4856v
Section 4856v. 619.14 (5) (e) of the statutes is amended to read:
619.14 (5) (e) Using the procedure under s. 227.24, the commissioner may promulgate rules under par. (a) or s. 619.146 (2) (b) for the schedule of premiums for the period before the effective date of any permanent rules promulgated under par. (a) or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner is not required to make a finding of emergency.
