AB100-ASA1-AA8-AA8,5,2322
619.10
(3g) "Governmental plan" has the meaning given under section 3 (32)
23of the federal Employee Retirement Income Security Act of 1974.
AB100-ASA1-AA8-AA8,5,2525
619.10
(3j) "Group health plan" means any of the following:
AB100-ASA1-AA8-AA8,6,5
1(a) An employe welfare plan, as defined in section 3 (1) of the federal Employee
2Retirement Security Act of 1974, to the extent that the employe welfare plan provides
3medical care, including items and services paid for as medical care, to employes or
4to their dependents, as defined under the terms of the employe welfare plan, directly
5or through insurance, reimbursement or otherwise.
AB100-ASA1-AA8-AA8,6,116
(b) Any program that would not otherwise be an employe welfare benefit plan
7and that is established or maintained by a partnership, to the extent that the
8program provides medical care, including items and services paid for as medical care,
9to present or former partners of the partnership or to their dependents, as defined
10under the terms of the program, directly or through insurance, reimbursement or
11otherwise.
AB100-ASA1-AA8-AA8,6,1713
619.10
(8j) "Preexisting condition exclusion" means, with respect to coverage,
14a limitation or exclusion of benefits relating to a condition of an individual that
15existed before the individual's date of enrollment for coverage, whether or not the
16individual received any medical advice or recommendation, diagnosis, care or
17treatment related to the condition before that date.
AB100-ASA1-AA8-AA8,7,419
619.10
(9) "Resident" means a person who has been legally domiciled in this
20state for a period of at least 30 days
or, with respect to an eligible individual, an
21individual who resides in this state. For purposes of this subchapter, legal domicile
22is established by living in this state and obtaining a Wisconsin motor vehicle
23operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax
24return. A child is legally domiciled in this state if the child lives in this state and if
25at least one of the child's parents or the child's guardian is legally domiciled in this
1state. A person with a developmental disability or another disability which prevents
2the person from obtaining a Wisconsin motor vehicle operator's license, registering
3to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in
4this state by living in this state for 30 days.
AB100-ASA1-AA8-AA8,7,10
6619.115 Rules relating to creditable coverage. The commissioner shall
7promulgate rules that specify how creditable coverage is to be aggregated for
8purposes of s. 619.10 (2t) (a) and that determine the creditable coverage to which s.
9619.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L.
10104-191.
AB100-ASA1-AA8-AA8,7,1912
619.12
(1) (intro.) Except as provided in subs. (1m) and (2), the board or
13administering carrier shall certify as eligible a person who is covered by medicare
14because he or she is disabled under
42 USC 423, a person who submits evidence that
15he or she has tested positive for the presence of HIV, antigen or nonantigenic
16products of HIV or an antibody to HIV,
a person who is an eligible individual, and any
17person who receives and submits any of the following based wholly or partially on
18medical underwriting considerations within 9 months prior to making application
19for coverage by the plan:
AB100-ASA1-AA8-AA8,7,2321
619.12
(2) (b) 2. Subdivision 1. does not apply
to any person who is an eligible
22individual or to any person who terminates coverage under the plan because he or
23she is receiving, or is eligible to receive, medical assistance benefits.
AB100-ASA1-AA8-AA8,8,2
1619.12
(2) (c) No person on whose behalf the plan has paid out
$500,000 2$1,000,000 or more is eligible for coverage under the plan.
AB100-ASA1-AA8-AA8,8,54
619.12
(2) (d)
No Except for a person who is an eligible individual, no person
5who is 65 years of age or older is eligible for coverage under the plan.
AB100-ASA1-AA8-AA8, s. 4830km
6Section 4830km. 619.12 (2) (e) of the statutes, as affected by 1997 Wisconsin
7Act .... (this act), is amended to read:
AB100-ASA1-AA8-AA8,8,118
619.12
(2) (e) No person who is eligible for
health care benefits creditable
9coverage, other than those benefits specified in s. 632.745 (11) (b) 1. to 12., that
are 10is provided by an employer on a self-insured basis or through health insurance is
11eligible for coverage under the plan.
AB100-ASA1-AA8-AA8,8,1714
619.12
(2) (e)
Except as provided in subd. 2., no No person who is eligible for
15health care benefits
, other than those benefits specified in s. 632.745 (11) (b) 1. to 12.,
16that are provided by an employer on a self-insured basis or through health insurance
17is eligible for coverage under the plan.
AB100-ASA1-AA8-AA8,8,2221
619.12
(2) (f) No person who is eligible for medical assistance is eligible for
22coverage under the plan.
AB100-ASA1-AA8-AA8,9,424
619.12
(3) (a) Except as provided in pars. (b)
and to (c), no person is eligible for
25coverage under the plan for whom a premium, deductible or coinsurance amount is
1paid or reimbursed by a federal, state, county or municipal government or agency as
2of the first day of any term for which a premium amount is paid or reimbursed and
3as of the day after the last day of any term during which a deductible or coinsurance
4amount is paid or reimbursed.
AB100-ASA1-AA8-AA8,9,86
619.12
(3) (bm) Persons for whom premium costs for health insurance coverage
7are subsidized under s. 252.16 are not ineligible for coverage under the plan by
8reason of such payments.
AB100-ASA1-AA8-AA8,9,1512
619.13
(1) Every insurer shall participate in the cost of administering the plan,
13except the commissioner may by rule exempt as a class those insurers whose share
14as determined under
par. (b) sub. (2) would be so minimal as to not exceed the
15estimated cost of levying the assessment.
AB100-ASA1-AA8-AA8,9,2318
619.13
(2) Except as provided by a rule promulgated under s. 619.145 (4), every 19Every participating insurer shall share in the operating, administrative and subsidy
20expenses of the plan in proportion to the ratio of the insurer's total health care
21coverage revenue for residents of this state during the preceding calendar year to the
22aggregate health care coverage revenue of all participating insurers for residents of
23this state during the preceding calendar year, as determined by the commissioner.
AB100-ASA1-AA8-AA8, s. 4838m
1Section 4838m. 619.13 (1) (d) of the statutes is renumbered 619.13 (3), and
2619.13 (3) (a), as renumbered, is amended to read:
AB100-ASA1-AA8-AA8,10,73
619.13
(3) (a) Each insurer's proportion of participation under
par. (b) sub. (2) 4shall be determined annually by the commissioner based on annual statements and
5other reports filed by the insurer with the commissioner.
The commissioner shall
6assess an insurer for the insurer's proportion of participation based on the total
7assessments estimated under s. 619.143 (2) (a) 2.
AB100-ASA1-AA8-AA8,10,22
11619.144 (title)
Insurer assessments and provider discounts for
12premium and deductible reductions. If the moneys under s. 20.145 (7) (a) and
13(g) are insufficient to reimburse the plan for premium reductions under s. 619.165
14and deductible reductions under s. 619.14 (5) (a), or the commissioner determines
15that the moneys under s. 20.145 (7) (a) and (g) will be insufficient to reimburse the
16plan for premium reductions under s. 619.165 and deductible reductions under s.
17619.14 (5) (a), the commissioner shall, by rule, increase
in equal proportions the
18amount of the assessment
under sub. (1) (a) or levy an assessment against every
19insurer, or a combination of both, set under s. 619.143 (2) (a) 2. and the provider
20charges discount rate set under s. 619.143 (2) (a) 3., subject to s. 619.143 (1) (b) 1., 21sufficient to reimburse the plan for premium reductions under s. 619.165 and
22deductible reductions under s. 619.14 (5) (a).
AB100-ASA1-AA8-AA8,11,424
619.135
(3) In addition to the assessments under
subs. (1) (a) and (2) sub. (1),
25the commissioner may, by rule, establish an assessment to be levied against each
1insurer that issues a notice of rejection under s. 619.12 (1) (a) to a person who
2becomes eligible for and obtains coverage under the plan as a result of receiving the
3notice. Any assessments levied and collected under this subsection shall be credited
4to the appropriation under s. 20.145 (7) (g).
AB100-ASA1-AA8-AA8,11,126
619.14
(2) (a) The plan shall provide every eligible person who is not eligible
7for medicare with major medical expense coverage. Major medical expense coverage
8offered under the plan
under this section shall pay an eligible person's covered
9expenses, subject to sub. (3) and deductible and coinsurance payments authorized
10under sub. (5), up to a lifetime limit of
$500,000
$1,000,000 per covered individual.
11The maximum limit under this paragraph shall not be altered by the board, and no
12actuarially equivalent benefit may be substituted by the board.
AB100-ASA1-AA8-AA8,11,2314
619.14
(3) Covered expenses. (intro.) Except as restricted by cost containment
15provisions under s. 619.17 (4) and except as reduced by the board under s. 619.15 (3)
16(e)
or by the commissioner under s. 619.143 (2) (a) 3. or (3) or 619.144, covered
17expenses
for the coverage under this section shall be the usual and customary
18charges for the services provided by persons licensed under ch. 446. Except as
19restricted by cost containment provisions under s. 619.17 (4) and except as reduced
20by the board under s. 619.15 (3) (e)
or by the commissioner under s. 619.143 (2) (a)
213. or (3) or 619.144, covered expenses
for the coverage under this section shall also
22be the usual and customary charges for the following services and articles when
23prescribed by a physician licensed under ch. 448 or in another state:
AB100-ASA1-AA8-AA8,12,2
1619.14
(4) Exclusions. (intro.) Covered expenses
for the coverage under this
2section shall not include the following:
AB100-ASA1-AA8-AA8,12,74
619.14
(4) (a) Any charge for treatment for cosmetic purposes other than
5surgery for the repair or treatment of an injury or a congenital bodily defect.
Breast
6reconstruction incident to a mastectomy shall not be considered treatment for
7cosmetic purposes.
AB100-ASA1-AA8-AA8,12,149
619.14
(4m) Discounted payment is payment in full. A provider of a covered
10service or article shall accept as payment in full for the covered service or article the
11discounted reimbursement rate determined under ss. 619.143 (2) (a) 3. and (3),
12619.144 and 619.15 (3) (e) and may not bill an eligible person who receives the service
13or article for any amount by which the charge for the service or article is reduced
14under s. 619.143 (2) (a) 3. or (3), 619.144 or 619.15 (3) (e).
AB100-ASA1-AA8-AA8,12,1616
619.14
(5) (title)
Premiums, deductibles Deductibles and coinsurance.
AB100-ASA1-AA8-AA8,13,918
619.14
(5) (a) The plan shall offer a deductible in combination with appropriate
19premiums determined under this subchapter for major medical expense coverage
20required under this section. For coverage offered to those persons eligible for
21medicare, the plan shall offer a deductible equal to the deductible charged by part
22A of title XVIII of the federal social security act, as amended. The deductible
23amounts for all other eligible persons shall be dependent upon household income as
24determined under s. 619.165. For eligible persons under s. 619.165 (1) (b) 1., the
25deductible shall be $500. For eligible persons under s. 619.165 (1) (b) 2., the
1deductible shall be $600. For eligible persons under s. 619.165 (1) (b) 3., the
2deductible shall be $700. For eligible persons under s. 619.165 (1) (b) 4., the
3deductible shall be $800. For all other eligible persons who are not eligible for
4medicare, the deductible shall be $1,000. With respect to all eligible persons,
5expenses used to satisfy the deductible during the last 90 days of a calendar year
6shall also be applied to satisfy the deductible for the following calendar year.
The
7schedule of premiums shall be promulgated by rule by the commissioner. The
8commissioner shall set rates at 60% of the operating and administrative costs of the
9plan.
AB100-ASA1-AA8-AA8,13,1611
619.14
(5) (d) Notwithstanding pars. (a) to (c), the board may establish
12different deductible amounts, a different coinsurance percentage and different
13covered costs and deductible aggregate amounts from those specified in pars. (a) to
14(c) in accordance with cost containment provisions established by the commissioner
15under s. 619.17 (4) (a)
and for individuals who enroll in an alternative plan under s.
16619.145.
AB100-ASA1-AA8-AA8,13,2320
619.14
(6) (a)
No Except as provided in par. (b), no person who obtains coverage
21under the plan may be covered for any preexisting condition during the first 6 months
22of coverage under the plan if the person was diagnosed or treated for that condition
23during the 6 months immediately preceding the filing of an application with the plan.
AB100-ASA1-AA8-AA8,14,2
1619.14
(6) (b) An eligible individual who obtains coverage under the plan may
2not be subject to any preexisting condition exclusion under the plan.
AB100-ASA1-AA8-AA8,14,5
4619.143 Payment of plan costs. (1) The operating, administrative and
5subsidy costs of the plan shall be paid as follows:
AB100-ASA1-AA8-AA8,14,66
(a) First from the appropriation under s. 20.145 (7) (af).
AB100-ASA1-AA8-AA8,14,77
(b) The remainder of the costs as follows:
AB100-ASA1-AA8-AA8,14,88
1. A total of 60% from all of the following:
AB100-ASA1-AA8-AA8,14,99
a. The appropriations under s. 20.145 (7) (a) and (g).
AB100-ASA1-AA8-AA8,14,1110
b. Insurer assessments and provider reimbursement discounts under s.
11619.144.
AB100-ASA1-AA8-AA8,14,1312
c. Subject to sub. (2) (a) 1. and s. 619.146 (2) (b), premiums collected from
13eligible persons.
AB100-ASA1-AA8-AA8,14,1414
2. A total of 40% as follows:
AB100-ASA1-AA8-AA8,14,1615
a. Fifty percent from insurer assessments, excluding assessments under s.
16619.144 and moneys in the appropriation account under s. 20.145 (7) (g).
AB100-ASA1-AA8-AA8,14,1817
b. Fifty percent from discounts to provider reimbursement rates, excluding
18discounts under ss. 619.144 and 619.15 (3) (e).
AB100-ASA1-AA8-AA8,14,22
19(2) (a) Prior to each plan year, the commissioner, in consultation with the board,
20shall estimate the operating, administrative and subsidy costs of the plan for the new
21plan year and, taking into consideration the funds expected to be available under s.
2220.145 (7) (a), (af) and (g), do all of the following:
AB100-ASA1-AA8-AA8,15,323
1. By rule set premium rates for the new plan year, including the rates under
24s. 619.146 (2) (b), by estimating the rates necessary to equal the amount specified in
25sub. (1) (b) 1. c., except that a rate for coverage under s. 619.14 may not be less than
1135% nor more than 190% of the rate that a standard risk would be charged under
2an individual policy providing substantially the same coverage and deductibles as
3are provided under the plan.
AB100-ASA1-AA8-AA8,15,64
2. By rule set the total insurer assessments under s. 619.13 for the new plan
5year by estimating the amount necessary to equal the amount specified in sub. (1)
6(b) 2. a.
AB100-ASA1-AA8-AA8,15,97
3. By the same rule as required under subd. 2. set the rate at which provider
8charges shall be discounted for the new plan year by estimating the rate necessary
9to equal the amount specified in sub. (1) (b) 2. b.
AB100-ASA1-AA8-AA8,15,1410
(b) In setting the rates under par. (a) 1. and 3. and the amount under par. (a)
112. for the new plan year, the commissioner shall include any increase or decrease
12necessary to reflect the amount, if any, by which the rates and amount set under par.
13(a) for the current plan year differed from the rates and amount which would have
14equaled the amounts specified in sub. (1) in the current plan year.
AB100-ASA1-AA8-AA8,15,23
15(3) (a) If, during a plan year, the commissioner determines that the moneys
16under s. 20.145 (7) (a), (af) and (g), the amounts set under sub. (2) (a) and any
17increases in insurer assessments and provider discounts under s. 619.144 are not
18sufficient to cover plan costs, the commissioner may by rule increase the premium
19rates set under sub. (2) (a) 1. for the remainder of the plan year, subject to subs. (1)
20(b) 1. and (2) (a) 1. and s. 619.146 (2) (b), increase the assessments set under sub. (2)
21(a) 2. for the remainder of the plan year, subject to sub. (1) (b) 2. a., and increase the
22discount rate set under sub. (2) (a) 3. for the remainder of the plan year, subject to
23sub. (1) (b) 2. b.
AB100-ASA1-AA8-AA8,16,624
(b) If, after increasing premium rates, assessments and discount rates under
25par. (a), the commissioner determines that there will still be a deficit and that
1premium rates have been increased to the maximum extent allowable under par. (a),
2the commissioner shall further increase, in equal proportions, assessments set under
3sub. (2) (a) 2. and discount rates set under sub. (2) (a) 3., without regard to sub. (1)
4(b) 2. Insurers and providers affected by this paragraph may recover the assessment
5increase and the discount rate increase in the normal course of their respective
6businesses without time limitation, subject to s. 619.14 (4m).
AB100-ASA1-AA8-AA8,16,11
7(4) Using the procedure under s. 227.24, the commissioner may promulgate
8rules under sub. (2) or (3) for the period before the effective date of any permanent
9rules promulgated under sub. (2) or (3), but not to exceed the period authorized under
10s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the commissioner is
11not required to make a finding of emergency.
AB100-ASA1-AA8-AA8,16,16
12(5) Notwithstanding sub. (2) (a) (intro.), the commissioner shall set premium
13rates, insurer assessments and provider discount rates for the period beginning on
14January 1, 1998, and ending on June 30, 1998, in the manner provided in subs. (1),
15(2) (a), (3) and (4). This subsection applies to policies in effect on January 1, 1998,
16as well as to policies issued or renewed on or after January 1, 1998.
AB100-ASA1-AA8-AA8,16,22
19619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in
20addition to the coverage required under s. 619.14, the plan shall offer to all eligible
21persons a choice of coverage, as described in section 2744 (a) (1) (
C) of P.L.
104-191.
22Any such choice of coverage shall be major medical expense coverage.