Amendment AA8-AA8-ASA1-AB100

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.

AB100-ASA1-AA8-AA8, s. 4862m Section 4862m. 619.15 (1) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,18,15 619.15 (1) The plan shall operate subject to the supervision and approval of a board of governors consisting of representatives of 2 participating insurers which are nonprofit corporations, representatives of 2 other participating insurers, 3 health care provider representatives, including one representative of the State Medical Society of Wisconsin, one representative of the Wisconsin Health and Hospital Association and one representative of an integrated multidisciplinary health system, and 3 public members, including one representative of small businesses in the state, appointed by the commissioner for staggered 3-year terms. In addition, the commissioner, or a designated representative from the office of the commissioner, and the chairperson of the standing committee of each house of the legislature with jurisdiction over insurance shall be a member members of the board. The public members shall not be professionally affiliated with the practice of medicine, a hospital or an insurer. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the plan or the parent or spouse of such an individual. The commissioner or the commissioner's representative shall be the chairperson of the board. Board members, except the commissioner or the commissioner's representative and the chairpersons of the standing committees, shall be compensated at the rate of $50 per diem plus actual and necessary expenses.

AB100-ASA1-AA8-AA8, s. 4863m Section 4863m. 619.15 (2) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,18,22 619.15 (2) Annually, the board shall make a report to the members of the plan and to the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under s. 13.172 (3), and to the members of the plan summarizing the activities of the plan in the preceding calendar year. The annual report shall define the cost burden imposed by the plan on all policyholders in this state.

AB100-ASA1-AA8-AA8, s. 4863pm Section 4863pm. 619.15 (2m) of the statutes is created to read:

AB100-ASA1-AA8-AA8,19,3 619.15 (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.

AB100-ASA1-AA8-AA8, s. 4867cm Section 4867cm. 619.15 (3) (c) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,19,11 619.15 (3) (c) Collect assessments from all insurers to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board as provided under s. 619.143. Assessment of the insurers shall occur at the end of each calendar year or other fiscal year end established by the board. Assessments are due and payable within 30 days of receipt by the insurer of the assessment notice.

AB100-ASA1-AA8-AA8, s. 4869cm Section 4869cm. 619.15 (3) (e) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,19,17 619.15 (3) (e) Establish for payment of covered expenses, a payment rate that is 10% less than the charges approved by the administering carrier for reimbursement of covered expenses under s. 619.14 (3). A provider of a covered service or article may not bill an eligible person who receives the service or article for any amount by which the charge is reduced under this paragraph.

AB100-ASA1-AA8-AA8, s. 4869mm Section 4869mm. 619.15 (3) (f) of the statutes is created to read:

AB100-ASA1-AA8-AA8,19,20 619.15 (3) (f) In consultation with the office, establish a choice of coverage under s. 619.146.

AB100-ASA1-AA8-AA8, s. 4872mm Section 4872mm. 619.15 (4) (c) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4873mm Section 4873mm. 619.15 (4) (d) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4873pm Section 4873pm. 619.15 (4) (e) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4887cm Section 4887cm. 619.16 (3) (em) of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4890c Section 4890c. 619.165 (1) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,20,4 619.165 (1) (a) The Except as provided in s. 619.146 (2) (a), the board shall reduce the premiums established by the commissioner under s. 619.11 in conformity with ss. 619.14 (5) 619.143 and 619.17, for the eligible persons and in the manner set forth in pars. (b) to (d).

AB100-ASA1-AA8-AA8, s. 4891cm Section 4891cm. 619.165 (1) (d) of the statutes is renumbered 619.165 (1) (d) 1. and amended to read:

AB100-ASA1-AA8-AA8,20,9 619.165 (1) (d) 1. The Subject to subd. 2., the board shall establish and implement the method for determining the household income of an eligible person under par. (b).

AB100-ASA1-AA8-AA8, s. 4891mm Section 4891mm. 619.165 (1) (d) 2. of the statutes is created to read:

AB100-ASA1-AA8-AA8,20,13 619.165 (1) (d) 2. In determining household income under par. (b), the board may consider information submitted by an eligible person on a completed federal profit or loss from farming form, schedule F, if all of the following apply:

AB100-ASA1-AA8-AA8,20,14 a. The person is a farmer, as defined in s. 102.04 (3).

AB100-ASA1-AA8-AA8,20,16 b. The person was not eligible to claim the homestead credit under subch. VIII of ch. 71 in the preceding taxable year.

AB100-ASA1-AA8-AA8, s. 4891rm Section 4891rm. 619.165 (3) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,20,20 619.165 (3) The commissioner shall forward to the board moneys received under s. 20.145 (7) (a) and (g) in an amount sufficient to reimburse the plan for premium reductions under sub. (1) and deductible reductions under s. 619.14 (5) (a).

AB100-ASA1-AA8-AA8, s. 4895c Section 4895c. 619.167 of the statutes is repealed.

AB100-ASA1-AA8-AA8, s. 4897m Section 4897m. 619.17 (1) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,20,24 619.17 (1) Subject to s. 619.14 (5) (a) ss. 619.143 and 619.146 (2) (b), a rating plan calculated in accordance with generally accepted actuarial principles.

AB100-ASA1-AA8-AA8, s. 4900m Section 4900m. 619.17 (4) (a) of the statutes is amended to read:

AB100-ASA1-AA8-AA8,21,2 619.17 (4) (a) Cost containment provisions established by the commissioner by rule, including managed care requirements.

AB100-ASA1-AA8-AA8, s. 4901cm Section 4901cm. 619.175 of the statutes is amended to read:

AB100-ASA1-AA8-AA8,21,8 619.175 Waiver or exemption from provisions prohibited. Except as provided in s. 619.13 (1) (a), the commissioner may not waive, or authorize the board to waive, any of the requirements of this subchapter or exempt, or authorize the board to exempt, an individual or a class of individuals from any of the requirements of this subchapter.".".

AB100-ASA1-AA8-AA8,21,9 15. Page 445, line 23: after that line insert:

AB100-ASA1-AA8-AA8,21,11 "1371w. Page 1825, line 22: delete the material beginning with that line and ending with page 1826, line 2.".

AB100-ASA1-AA8-AA8,21,12 16. Page 473, line 12: after that line insert:

AB100-ASA1-AA8-AA8,21,14 "1373c. Page 1826, line 23: delete the material beginning with that line and ending with page 1827, line 5.".

AB100-ASA1-AA8-AA8,21,15 17. Page 521, line 2: after that line insert:

AB100-ASA1-AA8-AA8,21,16 "1455c. Page 1978, line 1: delete lines 1 to 9.".

AB100-ASA1-AA8-AA8,21,17 18. Page 521, line 19: delete that line and substitute:

AB100-ASA1-AA8-AA8,21,18 "1459c. Page 1982, line 6: delete lines 6 to 17.".

AB100-ASA1-AA8-AA8,21,19 19. Page 525, line 15: after that line insert:

AB100-ASA1-AA8-AA8,21,21 "1470c. Page 1987, line 18: delete the material beginning with that line and ending with page 1989, line 25.".