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Mandatory health insurance
10
risk-sharing plan
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149.10
(2f) "Commissioner" means the commissioner of insurance.
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149.10
(2m) "Department" means the department of health and family
15services.
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149.10
(4c) "Health maintenance organization" has the meaning given in s.
18609.01 (2).
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149.10
(4p) (a) "Insurance" includes any of the following:
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1. Risk distributing arrangements providing for compensation of damages or
22loss through the provision of services or benefits in kind rather than indemnity in
23money.
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2. Contracts of guaranty or suretyship entered into by the guarantor or surety
25as a business and not as merely incidental to a business transaction.
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13. Plans established and operated under ss. 185.981 to 185.985.
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(b) "Insurance" does not include a continuing care contract, as defined in s.
3647.01 (2).
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149.10
(5m) "Limited service health organization" has the meaning given in
6s. 609.01 (3).
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149.10
(8c) "Policy" means any document other than a group certificate used
9to prescribe in writing the terms of an insurance contract, including endorsements
10and riders and service contracts issued by motor clubs.
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149.10
(8j) "Preexisting condition exclusion" means, with respect to coverage,
13a limitation or exclusion of benefits relating to a condition of an individual that
14existed before the individual's date of enrollment for coverage, whether or not the
15individual received any medical advice or recommendation, diagnosis, care or
16treatment related to the condition before that date.
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149.10
(8m) "Preferred provider plan" has the meaning given in s. 609.01 (4).
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149.10
(8p) "Premium" means any consideration for an insurance policy, and
21includes assessments, membership fees or other required contributions or
22consideration, however designated.
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149.10
(10) "Secretary" means the secretary of health and family services.
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1149.10
(11) "State" means the same as in s. 990.01 (40) except that it also
2includes the Panama Canal Zone.
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149.12
(2) (f) No person who is eligible for medical assistance is eligible for
5coverage under the plan.
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149.14
(4m) Discounted payment is payment in full. A provider of a covered
8service or article shall accept as payment in full for the covered service or article the
9discounted reimbursement rate determined under ss. 149.143 (2) (a) 3. and (3),
10149.144 and 149.15 (3) (e) and may not bill an eligible person who receives the service
11or article for any amount by which the charge for the service or article is reduced
12under s. 149.143 (2) (a) 3. or (3), 149.144 or 149.15 (3) (e).
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14149.143 Payment of plan costs. (1) The department shall pay or recover the
15operating, administrative and subsidy costs of the plan as follows:
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(a) First from the appropriation under s. 20.435 (5) (af).
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(b) The remainder of the costs as follows:
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1. A total of 60% from all of the following:
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a. The appropriation under s. 20.435 (5) (ah).
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b. Insurer assessments and provider reimbursement discounts under s.
21149.144.
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c. Subject to sub. (2) (a) 1. and s. 149.146 (2) (b), premiums collected from
23eligible persons.
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2. A total of 40% as follows:
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1a. Fifty percent from insurer assessments, excluding assessments under s.
2149.144.
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b. Fifty percent from discounts to provider reimbursement rates, excluding
4discounts under ss. 149.144 and 149.15 (3) (e).
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5(2) (a) Prior to each plan year, the department shall estimate the operating,
6administrative and subsidy costs of the plan for the new plan year and, taking into
7consideration the funds expected to be available under s. 20.435 (5) (af) and (ah), do
8all of the following:
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1. By rule set premium rates for the new plan year, including the rates under
10s. 149.146 (2) (b), by estimating the rates necessary to equal the amount specified in
11sub. (1) (b) 1. c., except that a rate for coverage under s. 149.14 may not be less than
12150% nor more than 200% of the rate that a standard risk would be charged under
13an individual policy providing substantially the same coverage and deductibles as
14are provided under the plan.
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2. By rule set the total insurer assessments under s. 149.13 for the new plan
16year by estimating the amount necessary to equal the amount specified in sub. (1)
17(b) 2. a. and notify the commissioner of the amount.
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3. By the same rule set the rate at which provider charges shall be discounted
19for the new plan year by estimating the rate necessary to equal the amount specified
20in sub. (1) (b) 2. b.
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(b) In setting the rates under par. (a) 1. and 3. and the amount under par. (a)
222. for the new plan year, the department shall include any increase or decrease
23necessary to reflect the amount, if any, by which the rates and amount set under par.
24(a) for the current plan year differed from the rates and amount which would have
25equaled the amounts specified in sub. (1) in the current plan year.
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1(3) (a) If, during a plan year, the department determines that the moneys under
2s. 20.435 (5) (af) and (ah), the amounts set under sub. (2) (a) and any increases in
3insurer assessments and provider discounts under s. 149.144 are not sufficient to
4cover plan costs, the department may by rule increase the premium rates set under
5sub. (2) (a) 1. for the remainder of the plan year, subject to subs. (1) (b) 1. and (2) (a)
61. and s. 149.146 (2) (b), increase the assessments set under sub. (2) (a) 2. for the
7remainder of the plan year, subject to sub. (1) (b) 2. a., and increase the discount rate
8set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (b) 2.
9b.
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(b) If, after increasing premium rates, assessments and discount rates under
11par. (a), the department determines that there will still be a deficit and that premium
12rates have been increased to the maximum extent allowable under par. (a), the
13department shall further increase, in equal proportions, assessments set under sub.
14(2) (a) 2. and discount rates set under sub. (2) (a) 3., without regard to sub. (1) (b) 2.
15Insurers and providers affected by this paragraph may recover the assessment
16increase and the discount rate increase in the normal course of their respective
17businesses without time limitation, subject to s. 149.14 (4m).
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18(4) Using the procedure under s. 227.24, the department may promulgate rules
19under sub. (2) or (3) for the period before the effective date of any permanent rules
20promulgated under sub. (2) or (3), but not to exceed the period authorized under s.
21227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the department is not
22required to make a finding of emergency.
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23(5) Notwithstanding sub. (2) (a) (intro.), the department shall set premium
24rates, insurer assessments and provider discount rates for the period beginning on
25January 1, 1998, and ending on June 30, 1998, in the manner provided in subs. (1),
1(2) (a), (3) and (4). This subsection applies to policies in effect on January 1, 1998,
2as well as to policies issued or renewed on or after January 1, 1998.
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149.15
(2m) Annually, beginning in 1999, the board shall submit a report on
5or before June 30 to the legislature under s. 13.172 (2) and to the governor on the
6operation of the plan, including any recommendations for changes to the plan.
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8149.16 (title)
Plan administrator.
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149.16
(1) The department shall contract with an organization or other person
11to administer the plan.
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150.21
(1) The construction
or total replacement of a
new nursing home.
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150.21
(3) A capital expenditure
, other than a renovation or replacement, that
16exceeds $1,000,000 by or on behalf of a nursing home.
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150.21
(4) An expenditure
, other than a renovation or replacement, that
19exceeds $600,000 for clinical equipment by or on behalf of a nursing home.
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150.31
(4) The department may decrease the statewide bed limit in facilities
22primarily serving the developmentally disabled in order to account for any decreased
23use of beds at
the a state
centers center for the developmentally disabled due to the
24community integration program under s. 46.275.
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1150.31
(5t) The department shall decrease the statewide bed limits specified
2in sub. (1) to account for any reduction in the licensed bed capacity of a nursing home
3that has relinquished use of a bed, as specified in s. 49.45 (6m) (ap) 4.
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150.35
(3m) (a) 3. All applications for activities that are specified in s. 150.21
6(3)
, that are renovations with capital expenditures which do not exceed $1,500,000
7and that do not include additions, the replacement of a nursing home or an increase
8in the bed capacity of a nursing home.
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150.39
(2) The cost of
renovating or providing an equal number of nursing home
11beds or of an equal expansion would be consistent with the cost at similar nursing
12homes, and the applicant's per diem rates would be consistent with those of similar
13nursing homes.
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153.01
(4) "Department" means the department of health and family services.
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153.05
(1) (c) 1. Identification of charges in each hospital's most recent entire
20fiscal year for up to 100 charge elements, as selected by the
office department, and
21identification of the increase or decrease in charges for each of these charge elements
22from amounts charged during the hospital's entire fiscal year that is nearest in time
23to the hospital's most recent entire fiscal year.
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1153.05
(1) (e) Final audited financial statements of hospitals that include, for
2a hospital's most recent entire fiscal year, as dollar amounts, the amounts of revenue
3and expenditures for the hospital, in categories specified in rules promulgated by the
4commissioner department.
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153.05
(2) The
office department shall provide copies of reports published
7under ss. 153.10 to 153.35 at no charge to hospitals assessed under s. 153.60 (1) and,
8if assessed, at no charge to ambulatory surgery centers assessed under s. 153.60 (2).
9The
office department shall provide copies of the reports to any person, upon the
10person's request, and the board shall advise the
office department as to whether the
11copies shall be provided at no charge or at a charge not to exceed the cost of printing,
12copying and mailing the report to the person.
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153.05
(3) Upon request of the
office
department, state agencies shall provide
15health care information to the
office department for use in preparing reports under
16ss. 153.10 to 153.35.
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153.05
(4) (a) The
office department, under rules promulgated by the
19commissioner department, shall require hospitals to use, and private-pay patients
20and payers who are insurers to accept, uniform patient billing forms, shall require
21hospitals to submit to the
office department the information provided on the billing
22forms, including, for an injury, the external cause of the event, and may require
23payers who are insurers to use a standard set of definitions for base data reporting
24under a uniform patient billing form.
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1(b) The
office department, under rules promulgated by the
commissioner 2department, may require ambulatory surgery centers to use uniform patient billing
3forms and other information, and, if so requiring, shall require ambulatory surgery
4centers to submit to the
office department the information provided on the billing
5forms, including, for an injury, the external cause of the event, using a standard set
6of definitions for base data reporting.