Amendment AA8-AA8-ASA1-AB100

AB100-ASA1-AA8-AA8,4,5 4. Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.

AB100-ASA1-AA8-AA8,4,6 5. Chapter 55 of title 10 of the United States Code.

AB100-ASA1-AA8-AA8,4,8 6. A medical care program of the federal Indian health service or of an American Indian tribal organization.

AB100-ASA1-AA8-AA8,4,9 7. A state health benefits risk pool.

AB100-ASA1-AA8-AA8,4,10 8. A health plan offered under chapter 89 of title 5 of the United States Code.

AB100-ASA1-AA8-AA8,4,11 9. A public health plan.

AB100-ASA1-AA8-AA8,4,13 10. A health coverage plan under section 5 (e) of the federal Peace Corps Act, 22 USC 2504 (e).

AB100-ASA1-AA8-AA8,4,15 (b) "Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191.

AB100-ASA1-AA8-AA8, s. 4817g Section 4817g. 619.10 (2t) of the statutes is created to read:

AB100-ASA1-AA8-AA8,4,18 619.10 (2t) "Eligible individual" means an individual for whom all of the following apply:

AB100-ASA1-AA8-AA8,4,20 (a) The aggregate of the individual's periods of creditable coverage is 18 months or more.

AB100-ASA1-AA8-AA8,4,23 (b) The individual's most recent period of creditable coverage was under a group health plan, governmental plan, federal governmental plan or church plan, or under any health insurance offered in connection with any of those plans.

AB100-ASA1-AA8-AA8,5,2 (c) The individual does not have creditable coverage and is not eligible for coverage under a group health plan, part A or part B of title XVIII of the federal Social Security Act or a state plan under title XIX of the federal Social Security Act or any successor program.

AB100-ASA1-AA8-AA8,5,5 (d) The individual's most recent period of creditable coverage was not terminated for any reason related to fraud or intentional misrepresentation of material fact or a failure to pay premiums.

AB100-ASA1-AA8-AA8,5,8 (e) If the individual was offered the option of continuation coverage under a federal continuation provision or similar state program, the individual elected the continuation coverage.

AB100-ASA1-AA8-AA8,5,9 (f) The individual has exhausted any continuation coverage under par. (e).

AB100-ASA1-AA8-AA8, s. 4818c Section 4818c. 619.10 (3c) of the statutes is created to read:

AB100-ASA1-AA8-AA8,5,11 619.10 (3c) "Federal continuation provision" means any of the following:

AB100-ASA1-AA8-AA8,5,13 (a) Section 4980B of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.

AB100-ASA1-AA8-AA8,5,15 (b) Part 6 of subtitle B of title I of the federal Employee Retirement Income Security Act of 1974, except for section 609 of that act.

AB100-ASA1-AA8-AA8,5,16 (c) Title XXII of P.L. 104-191.

AB100-ASA1-AA8-AA8, s. 4818f Section 4818f. 619.10 (3d) of the statutes is created to read:

AB100-ASA1-AA8-AA8,5,20 619.10 (3d) "Federal governmental plan" means a benefit program established or maintained for its employes by the government of the United States or by any agency or instrumentality of the government of the United States.

AB100-ASA1-AA8-AA8, s. 4818j Section 4818j. 619.10 (3g) of the statutes is created to read:

AB100-ASA1-AA8-AA8,5,23 619.10 (3g) "Governmental plan" has the meaning given under section 3 (32) of the federal Employee Retirement Income Security Act of 1974.

AB100-ASA1-AA8-AA8, s. 4818m Section 4818m. 619.10 (3j) of the statutes is created to read:

AB100-ASA1-AA8-AA8,5,25 619.10 (3j) "Group health plan" means any of the following:

AB100-ASA1-AA8-AA8,6,5 (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.

AB100-ASA1-AA8-AA8,6,11 (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.

AB100-ASA1-AA8-AA8, s. 4823m Section 4823m. 619.10 (8j) of the statutes is created to read:

AB100-ASA1-AA8-AA8,6,17 619.10 (8j) "Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition of an individual that existed before the individual's date of enrollment for coverage, whether or not the individual received any medical advice or recommendation, diagnosis, care or treatment related to the condition before that date.

AB100-ASA1-AA8-AA8, s. 4824p Section 4824p. 619.10 (9) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,7,4 619.10 (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, 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.

AB100-ASA1-AA8-AA8, s. 4825g Section 4825g. 619.115 of the statutes is created to read:

AB100-ASA1-AA8-AA8,7,10 619.115 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.

AB100-ASA1-AA8-AA8, s. 4827f Section 4827f. 619.12 (1) (intro.) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,7,19 619.12 (1) (intro.) Except as provided in subs. (1m) and (2), the board or administering carrier 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:

AB100-ASA1-AA8-AA8, s. 4830hm Section 4830hm. 619.12 (2) (b) 2. of the statutes is amended to read:

AB100-ASA1-AA8-AA8,7,23 619.12 (2) (b) 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.

AB100-ASA1-AA8-AA8, s. 4830im Section 4830im. 619.12 (2) (c) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,8,2 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4830jm Section 4830jm. 619.12 (2) (d) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,8,5 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4830km Section 4830km. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin Act .... (this act), is amended to read:

AB100-ASA1-AA8-AA8,8,11 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4830kr Section 4830kr. 619.12 (2) (e) 1. of the statutes is renumbered 619.12 (2) (e) and amended to read:

AB100-ASA1-AA8-AA8,8,17 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4830Lm Section 4830Lm. 619.12 (2) (e) 2. of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4830mm Section 4830mm. 619.12 (2) (e) 3. of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4830r Section 4830r. 619.12 (2) (f) of the statutes is created to read:

AB100-ASA1-AA8-AA8,8,22 619.12 (2) (f) No person who is eligible for medical assistance is eligible for coverage under the plan.

AB100-ASA1-AA8-AA8, s. 4831nm Section 4831nm. 619.12 (3) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,9,4 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4831pm Section 4831pm. 619.12 (3) (bm) of the statutes is created to read:

AB100-ASA1-AA8-AA8,9,8 619.12 (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.

AB100-ASA1-AA8-AA8, s. 4831rm Section 4831rm. 619.123 of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4835m Section 4835m. 619.13 (1) (a) of the statutes is renumbered 619.13 (1) and amended to read:

AB100-ASA1-AA8-AA8,9,15 619.13 (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.

AB100-ASA1-AA8-AA8, s. 4836m Section 4836m. 619.13 (1) (b) of the statutes is renumbered 619.13 (2) and amended to read:

AB100-ASA1-AA8-AA8,9,23 619.13 (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.

AB100-ASA1-AA8-AA8, s. 4837m Section 4837m. 619.13 (1) (c) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4838m Section 4838m. 619.13 (1) (d) of the statutes is renumbered 619.13 (3), and 619.13 (3) (a), as renumbered, is amended to read:

AB100-ASA1-AA8-AA8,10,7 619.13 (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 under s. 619.143 (2) (a) 2.

AB100-ASA1-AA8-AA8, s. 4839cm Section 4839cm. 619.13 (2) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4845cm Section 4845cm. 619.135 (2) of the statutes is renumbered 619.144 and amended to read:

AB100-ASA1-AA8-AA8,10,22 619.144 (title) Insurer assessments and provider discounts for premium and deductible reductions. 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 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. 619.143 (2) (a) 2. and the provider charges discount rate set under s. 619.143 (2) (a) 3., subject to s. 619.143 (1) (b) 1., sufficient to reimburse the plan for premium reductions under s. 619.165 and deductible reductions under s. 619.14 (5) (a).

AB100-ASA1-AA8-AA8, s. 4846cm Section 4846cm. 619.135 (3) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,11,4 619.135 (3) In addition to the assessments under subs. (1) (a) and (2) sub. (1), 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).

AB100-ASA1-AA8-AA8, s. 4849cm Section 4849cm. 619.14 (2) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,11,12 619.14 (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.

AB100-ASA1-AA8-AA8, s. 4849fm Section 4849fm. 619.14 (3) (intro.) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,11,23 619.14 (3) Covered expenses. (intro.) Except as restricted by cost containment provisions under s. 619.17 (4) and except as reduced by the board under s. 619.15 (3) (e) or by the commissioner under s. 619.143 (2) (a) 3. or (3) or 619.144, 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. Except as restricted by cost containment provisions under s. 619.17 (4) and except as reduced by the board under s. 619.15 (3) (e) or by the commissioner under s. 619.143 (2) (a) 3. or (3) or 619.144, covered expenses for the coverage under this section shall also be the usual and customary charges for the following services and articles when prescribed by a physician licensed under ch. 448 or in another state:

AB100-ASA1-AA8-AA8, s. 4850cm Section 4850cm. 619.14 (4) (intro.) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,12,2 619.14 (4) Exclusions. (intro.) Covered expenses for the coverage under this section shall not include the following:

AB100-ASA1-AA8-AA8, s. 4850dh Section 4850dh. 619.14 (4) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,12,7 619.14 (4) (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 incident to a mastectomy shall not be considered treatment for cosmetic purposes.

AB100-ASA1-AA8-AA8, s. 4850fm Section 4850fm. 619.14 (4m) of the statutes is created to read:

AB100-ASA1-AA8-AA8,12,14 619.14 (4m) Discounted payment is payment in full. A provider of a covered service or article shall accept as payment in full for the covered service or article the discounted reimbursement rate determined under ss. 619.143 (2) (a) 3. and (3), 619.144 and 619.15 (3) (e) 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 s. 619.143 (2) (a) 3. or (3), 619.144 or 619.15 (3) (e).

AB100-ASA1-AA8-AA8, s. 4850hm Section 4850hm. 619.14 (5) (title) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,12,16 619.14 (5) (title) Premiums, deductibles Deductibles and coinsurance.

AB100-ASA1-AA8-AA8, s. 4850mm Section 4850mm. 619.14 (5) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,13,9 619.14 (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. The commissioner shall set rates at 60% of the operating and administrative costs of the plan.

AB100-ASA1-AA8-AA8, s. 4853cm Section 4853cm. 619.14 (5) (d) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,13,16 619.14 (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.

AB100-ASA1-AA8-AA8, s. 4854mm Section 4854mm. 619.14 (5) (e) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4855mm Section 4855mm. 619.14 (6) of the statutes is renumbered 619.14 (6) (a) and amended to read:

AB100-ASA1-AA8-AA8,13,23 619.14 (6) (a) No Except as provided in par. (b), no person who obtains coverage under the plan may be covered for any preexisting condition during the first 6 months of coverage under the plan if the person was diagnosed or treated for that condition during the 6 months immediately preceding the filing of an application with the plan.

AB100-ASA1-AA8-AA8, s. 4856mm Section 4856mm. 619.14 (6) (b) of the statutes is created to read:

AB100-ASA1-AA8-AA8,14,2 619.14 (6) (b) An eligible individual who obtains coverage under the plan may not be subject to any preexisting condition exclusion under the plan.