Amendment AA8-AA8-ASA1-AB100

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.

AB100-ASA1-AA8-AA8, s. 4857d Section 4857d. 619.143 of the statutes is created to read:

AB100-ASA1-AA8-AA8,14,5 619.143 Payment of plan costs. (1) The operating, administrative and subsidy costs of the plan shall be paid as follows:

AB100-ASA1-AA8-AA8,14,6 (a) First from the appropriation under s. 20.145 (7) (af).

AB100-ASA1-AA8-AA8,14,7 (b) The remainder of the costs as follows:

AB100-ASA1-AA8-AA8,14,8 1. A total of 60% from all of the following:

AB100-ASA1-AA8-AA8,14,9 a. The appropriations under s. 20.145 (7) (a) and (g).

AB100-ASA1-AA8-AA8,14,11 b. Insurer assessments and provider reimbursement discounts under s. 619.144.

AB100-ASA1-AA8-AA8,14,13 c. Subject to sub. (2) (a) 1. and s. 619.146 (2) (b), premiums collected from eligible persons.

AB100-ASA1-AA8-AA8,14,14 2. A total of 40% as follows:

AB100-ASA1-AA8-AA8,14,16 a. Fifty percent from insurer assessments, excluding assessments under s. 619.144 and moneys in the appropriation account under s. 20.145 (7) (g).

AB100-ASA1-AA8-AA8,14,18 b. Fifty percent from discounts to provider reimbursement rates, excluding discounts under ss. 619.144 and 619.15 (3) (e).

AB100-ASA1-AA8-AA8,14,22 (2) (a) Prior to each plan year, the commissioner, in consultation with the board, shall estimate the operating, administrative and subsidy costs of the plan for the new plan year and, taking into consideration the funds expected to be available under s. 20.145 (7) (a), (af) and (g), do all of the following:

AB100-ASA1-AA8-AA8,15,3 1. By rule set premium rates for the new plan year, including the rates under s. 619.146 (2) (b), by estimating the rates necessary to equal the amount specified in sub. (1) (b) 1. c., except that a rate for coverage under s. 619.14 may not be less than 135% nor more than 190% 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.

AB100-ASA1-AA8-AA8,15,6 2. By rule set the total insurer assessments under s. 619.13 for the new plan year by estimating the amount necessary to equal the amount specified in sub. (1) (b) 2. a.

AB100-ASA1-AA8-AA8,15,9 3. By the same rule as required under subd. 2. set the rate at which provider charges shall be discounted for the new plan year by estimating the rate necessary to equal the amount specified in sub. (1) (b) 2. b.

AB100-ASA1-AA8-AA8,15,14 (b) In setting the rates under par. (a) 1. and 3. and the amount under par. (a) 2. for the new plan year, the commissioner 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) in the current plan year.

AB100-ASA1-AA8-AA8,15,23 (3) (a) If, during a plan year, the commissioner determines that the moneys under s. 20.145 (7) (a), (af) and (g), the amounts set under sub. (2) (a) and any increases in insurer assessments and provider discounts under s. 619.144 are not sufficient to cover plan costs, the commissioner may by rule increase the premium rates set under sub. (2) (a) 1. for the remainder of the plan year, subject to subs. (1) (b) 1. and (2) (a) 1. and s. 619.146 (2) (b), increase the assessments set under sub. (2) (a) 2. for the remainder of the plan year, subject to sub. (1) (b) 2. a., and increase the discount rate set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (b) 2. b.

AB100-ASA1-AA8-AA8,16,6 (b) If, after increasing premium rates, assessments and discount rates under par. (a), the commissioner determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the commissioner shall further increase, in equal proportions, assessments set under sub. (2) (a) 2. and discount rates set under sub. (2) (a) 3., without regard to sub. (1) (b) 2. Insurers and providers affected by this paragraph may recover the assessment increase and the discount rate increase in the normal course of their respective businesses without time limitation, subject to s. 619.14 (4m).

AB100-ASA1-AA8-AA8,16,11 (4) Using the procedure under s. 227.24, the commissioner 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 commissioner is not required to make a finding of emergency.

AB100-ASA1-AA8-AA8,16,16 (5) Notwithstanding sub. (2) (a) (intro.), the commissioner shall set premium rates, insurer assessments and provider discount 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.

AB100-ASA1-AA8-AA8, s. 4859cm Section 4859cm. 619.145 of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4859mm Section 4859mm. 619.146 of the statutes is created to read:

AB100-ASA1-AA8-AA8,16,22 619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in addition to the coverage required under s. 619.14, the plan shall offer to all eligible persons a choice of coverage, as described in section 2744 (a) (1) (C) of P.L. 104-191. Any such choice of coverage shall be major medical expense coverage.

AB100-ASA1-AA8-AA8,17,6 (b) An eligible person may elect once each year, at the time and according to procedures established by the board, among the coverages offered under this section and s. 619.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this subchapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this subchapter and the person remained continuously covered under this subchapter up to the time of electing new coverage.

AB100-ASA1-AA8-AA8,17,10 (2) (a) Except as specified by the board, the terms of coverage under s. 619.14, including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage offered under this section. Premium reductions under s. 619.165 do not apply to the coverage offered under this section.

AB100-ASA1-AA8-AA8,17,15 (b) The schedule of premiums for coverage under this section shall be promulgated by rule by the commissioner, as provided in s. 619.143. The rates for coverage under this section shall be set such that they differ from the rates for coverage under s. 619.14 by the same percentage as the percentage difference between the following:

AB100-ASA1-AA8-AA8,17,18 1. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as provided under s. 619.14.

AB100-ASA1-AA8-AA8,17,21 2. The rate that a standard risk would be charged under an individual policy providing substantially the same coverage and deductibles as the coverage offered under this section.