SB77-SSA1, s. 4840c
23Section 4840c. 619.135 (title) of the statutes is renumbered 149.144 (title) and
24amended to read:
SB77-SSA1,1813,2
1149.144 (title)
Insurer assessments and provider discounts for
2premium and deductible reductions.
SB77-SSA1, s. 4845c
4Section 4845c. 619.135 (2) of the statutes is renumbered 149.144 and
5amended to read:
SB77-SSA1,1813,19
6149.144 If the moneys under s.
20.145 (7) (a) and (g) 20.435 (5) (ah) are
7insufficient to reimburse the plan for premium reductions under s.
619.165 149.165 8and deductible reductions under s.
619.14 149.14 (5) (a), or the
commissioner 9department determines that the moneys under s.
20.145 (7) (a) and (g) 20.435 (5) (ah) 10will be insufficient to reimburse the plan for premium reductions under s.
619.165 11149.165 and deductible reductions under s.
619.14 149.14 (5) (a), the
commissioner 12department shall, by rule, increase
in equal proportions the amount of the
13assessment
under sub. (1) (a) or levy an assessment against every insurer, or a
14combination of both, set under s. 149.143 (2) (a) 2. and the provider charges discount
15rate set under s. 149.143 (2) (a) 3., subject to s. 149.143 (1) (b) 1., sufficient to
16reimburse the plan for premium reductions under s.
619.165 149.165 and deductible
17reductions under s.
619.14 149.14 (5) (a).
The department shall notify the
18commissioner so that the commissioner may levy the increase in the insurer
19assessments.
SB77-SSA1, s. 4847
21Section
4847. 619.14 (title) of the statutes is renumbered 149.14 (title).
SB77-SSA1, s. 4848
22Section
4848. 619.14 (1) of the statutes is renumbered 149.14 (1), and 149.14
23(1) (b), as renumbered, is amended to read:
SB77-SSA1,1814,324
149.14
(1) (b) If an individual terminates medical assistance coverage and
25applies for coverage under the plan within 45 days after the termination and is
1subsequently found to be eligible under s.
619.12 149.12, the effective date of
2coverage for the eligible person under the plan shall be the date of termination of
3medical assistance coverage.
SB77-SSA1, s. 4849
4Section
4849. 619.14 (2) of the statutes is renumbered 149.14 (2), and 149.14
5(2) (a), as renumbered, is amended to read:
SB77-SSA1,1814,126
149.14
(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.
SB77-SSA1, s. 4850
13Section
4850. 619.14 (3) of the statutes is renumbered 149.14 (3), and 149.14
14(3) (intro.) and (c) 3., as renumbered, are amended to read:
SB77-SSA1,1814,2515
149.14
(3) Covered expenses. (intro.) Except as restricted by cost containment
16provisions under s.
619.17 149.17 (4) and except as reduced by the board under s.
17619.15 149.15 (3) (e)
or by the department under s. 149.143 (2) (a) 3. or (3) or 149.144,
18covered expenses
for the coverage under this section shall be the usual and
19customary charges for the services provided by persons licensed under ch. 446.
20Except as restricted by cost containment provisions under s.
619.17 149.17 (4) and
21except as reduced by the board under s.
619.15 149.15 (3) (e)
or by the department
22under s. 149.143 (2) (a) 3. or (3) or 149.144, covered expenses
for the coverage under
23this section shall also be the usual and customary charges for the following services
24and articles when prescribed by a physician licensed under ch. 448 or in another
25state:
SB77-SSA1,1815,3
1 (c) 3. Subject to the limits under subd. 2. and to rules promulgated by the
2commissioner department, services for the chronically mentally ill in community
3support programs operated under s. 51.421.
SB77-SSA1, s. 4851
4Section
4851. 619.14 (4) of the statutes is renumbered 149.14 (4), and 149.14
5(4) (intro.) and (m), as renumbered, are amended to read:
SB77-SSA1,1815,76
149.14
(4) Exclusions. (intro.) Covered expenses
for the coverage under this
7section shall not include the following:
SB77-SSA1,1815,98
(m) Experimental treatment, as determined by the
board or its designee 9department.
SB77-SSA1, s. 4852c
10Section 4852c. 619.14 (5) (title) of the statutes is renumbered 149.14 (5) (title)
11and amended to read:
SB77-SSA1,1815,1212
149.14
(5) (title)
Premiums, deductibles Deductibles and coinsurance.
SB77-SSA1, s. 4853
13Section
4853. 619.14 (5) (a) of the statutes is renumbered 149.14 (5) (a) and
14amended to read:
SB77-SSA1,1816,615
149.14
(5) (a) The plan shall offer a deductible in combination with appropriate
16premiums determined under this
subchapter chapter for major medical expense
17coverage required under this section. For coverage offered to those persons eligible
18for medicare, the plan shall offer a deductible equal to the deductible charged by part
19A of title XVIII of the federal social security act, as amended. The deductible
20amounts for all other eligible persons shall be dependent upon household income as
21determined under s.
619.165 149.165. For eligible persons under s.
619.165 (1) (b)
221. 149.165 (2) (a), the deductible shall be $500. For eligible persons under s.
619.165
23(1) (b) 2. 149.165 (2) (b), the deductible shall be $600. For eligible persons under s.
24619.165 (1) (b) 3. 149.165 (2) (c), the deductible shall be $700. For eligible persons
25under s.
619.165 (1) (b) 4. 149.165 (2) (d), the deductible shall be $800. For all other
1eligible persons who are not eligible for medicare, the deductible shall be $1,000.
2With respect to all eligible persons, expenses used to satisfy the deductible during
3the last 90 days of a calendar year shall also be applied to satisfy the deductible for
4the following calendar year.
The schedule of premiums shall be promulgated by rule
5by the commissioner. The commissioner shall set rates at 60% of the operating and
6administrative costs of the plan.
SB77-SSA1, s. 4854c
7Section 4854c. 619.14 (5) (b) of the statutes is renumbered 149.14 (5) (b).
SB77-SSA1, s. 4855c
8Section 4855c. 619.14 (5) (c) of the statutes is renumbered 149.14 (5) (c)
SB77-SSA1, s. 4856
9Section
4856. 619.14 (5) (d) of the statutes is renumbered 149.14 (5) (d) and
10amended to read:
SB77-SSA1,1816,1611
149.14
(5) (d) Notwithstanding pars. (a) to (c), the
board department may
12establish different deductible amounts, a different coinsurance percentage and
13different covered costs and deductible aggregate amounts from those specified in
14pars. (a) to (c) in accordance with cost containment provisions established by the
15commissioner department under s.
619.17 (4) (a) and for individuals who enroll in
16an alternative plan under s. 619.145 149.17 (4).
SB77-SSA1,1816,2318
619.14
(5) (e) Using the procedure under s. 227.24, the commissioner may
19promulgate rules under par. (a)
or s. 619.146 (2) (b) for the schedule of premiums for
20the period before the effective date of any permanent rules promulgated under par.
21(a)
or s. 619.146 (2) (b) for the schedule of premiums, but not to exceed the period
22authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the
23commissioner is not required to make a finding of emergency.
SB77-SSA1, s. 4857c
24Section 4857c. 619.14 (5) (e) of the statutes, as affected by 1997 Wisconsin Act
25.... (this act), is repealed.
SB77-SSA1, s. 4858b
1Section 4858b. 619.14 (6) of the statutes is renumbered 619.14 (6) (a) and
2amended to read:
SB77-SSA1,1817,63
619.14
(6) (a)
No Except as provided in par. (b), no person who obtains coverage
4under the plan may be covered for any preexisting condition during the first 6 months
5of coverage under the plan if the person was diagnosed or treated for that condition
6during the 6 months immediately preceding the filing of an application with the plan.
SB77-SSA1, s. 4858c
7Section 4858c. 619.14 (6) of the statutes, as affected by 1997 Wisconsin Act
8.... (this act), is renumbered 149.14 (6).
SB77-SSA1,1817,1510
619.14
(6) (b) An eligible individual who obtains coverage under the plan on
11or after the effective date of this paragraph .... [revisor inserts date], may not be
12subject to any preexisting condition exclusion under the plan. An eligible individual
13who is covered under the plan on the effective date of this paragraph .... [revisor
14inserts date], may not be subject to any preexisting condition exclusion on or after
15the effective date of this paragraph .... [revisor inserts date].
SB77-SSA1, s. 4859
16Section
4859. 619.14 (7) of the statutes is renumbered 149.14 (7), and 149.14
17(7) (b) and (c), as renumbered, are amended to read:
SB77-SSA1,1817,2118
149.14
(7) (b) The
board department has a cause of action against an eligible
19participant for the recovery of the amount of benefits paid which are not for covered
20expenses under the plan. Benefits under the plan may be reduced or refused as a
21setoff against any amount recoverable under this paragraph.
SB77-SSA1,1817,2522
(c) The
board department is subrogated to the rights of an eligible person to
23recover special damages for illness or injury to the person caused by the act of a 3rd
24person to the extent that benefits are provided under the plan.
Section 814.03 (3)
25applies to the department under this paragraph.
SB77-SSA1,1818,6
3619.146 Choice of coverage. (1) (a) Beginning on January 1, 1998, in
4addition to the coverage required under s. 619.14, the plan shall offer to all eligible
5persons a choice of coverage, as described in section 2744 (a) (1) (
C) of P.L.
104-191.
6Any such choice of coverage shall be major medical expense coverage.
SB77-SSA1,1818,157
(b) An eligible person may elect once each year, at the time and according to
8procedures established by the board, among the coverages offered under this section
9and s. 619.14. If an eligible person elects new coverage, any preexisting condition
10exclusion imposed under the new coverage is met to the extent that the eligible
11person has been previously and continuously covered under this subchapter. No
12preexisting condition exclusion may be imposed on an eligible person who elects new
13coverage if the person was an eligible individual when first covered under this
14subchapter and the person remained continuously covered under this subchapter up
15to the time of electing new coverage.
SB77-SSA1,1818,19
16(2) (a) Except as specified by the board, the terms of coverage under s. 619.14,
17including deductible reductions under s. 619.14 (5) (a), do not apply to the coverage
18offered under this section. Premium reductions under s. 619.165 do not apply to the
19coverage offered under this section.
SB77-SSA1,1818,2320
(b) The schedule of premiums for coverage under this section shall be
21promulgated by rule by the commissioner. The rates for coverage under this section
22shall be set such that they differ from the rates for coverage under s. 619.14 by the
23same percentage as the percentage difference between the following:
SB77-SSA1,1819,3
11. The rate that a standard risk would be charged under an individual policy
2providing substantially the same coverage and deductibles as provided under s.
3619.14.
SB77-SSA1,1819,64
2. The rate that a standard risk would be charged under an individual policy
5providing substantially the same coverage and deductibles as the coverage offered
6under this section.
SB77-SSA1, s. 4860d
7Section 4860d. 619.146 of the statutes, as created by 1997 Wisconsin Act ....
8(this act), is renumbered 149.146, and 149.146 (1) (a) and (b) and (2) (a) and (b)
9(intro.) and 1., as renumbered, are amended to read:
SB77-SSA1,1819,1310
149.146
(1) (a) Beginning on January 1, 1998, in addition to the coverage
11required under s.
619.14 149.14, the plan shall offer to all eligible persons a choice
12of coverage, as described in section 2744 (a) (1) (
C), P.L.
104-191. Any such choice
13of coverage shall be major medical expense coverage.
SB77-SSA1,1819,2214
(b) An eligible person may elect once each year, at the time and according to
15procedures established by the board, among the coverages offered under this section
16and s.
619.14 149.14. If an eligible person elects new coverage, any preexisting
17condition exclusion imposed under the new coverage is met to the extent that the
18eligible person has been previously and continuously covered under this
subchapter 19chapter. No preexisting condition exclusion may be imposed on an eligible person
20who elects new coverage if the person was an eligible individual when first covered
21under this
subchapter chapter and the person remained continuously covered under
22this
subchapter chapter up to the time of electing the new coverage.
SB77-SSA1,1820,2
23(2) (a) Except as specified by the board, the terms of coverage under s.
619.14 24149.14, including deductible reductions under s.
619.14 149.14 (5) (a), do not apply
1to the coverage offered under this section. Premium reductions under s.
619.165 2149.165 do not apply to the coverage offered under this section.
SB77-SSA1,1820,73
(b) (intro.) The schedule of premiums for coverage under this section shall be
4promulgated by rule by the
commissioner department, as provided in s. 149.143. The
5rates for coverage under this section shall be set such that they differ from the rates
6for coverage under s.
619.14 149.14 by the same percentage as the percentage
7difference between the following:
SB77-SSA1,1820,108
1. The rate that a standard risk would be charged under an individual policy
9providing substantially the same coverage and deductibles as provided under s.
10619.14 149.14.
SB77-SSA1, s. 4861
11Section
4861. 619.15 (title) of the statutes is renumbered 149.15 (title).
SB77-SSA1, s. 4862
12Section
4862. 619.15 (1) of the statutes is renumbered 149.15 (1) and amended
13to read:
SB77-SSA1,1821,614
149.15
(1) The plan shall
operate subject to the supervision and approval of a
15have a board
of governors consisting of representatives of 2 participating insurers
16which are nonprofit corporations,
representatives of 2 other participating insurers,
173 health care provider representatives, including one representative of the State
18Medical Society of Wisconsin, one representative of the Wisconsin Health and
19Hospital Association and one representative of an integrated multidisciplinary
20health system, and 3 public members,
including one representative of small
21businesses in the state, appointed by the
commissioner secretary for staggered
223-year terms. In addition, the commissioner
, or a designated representative from
23the office of the commissioner
, and the secretary, or a designated representative from
24the department, shall be
a member members of the board. The public members shall
25not be professionally affiliated with the practice of medicine, a hospital or an insurer.
1At least 2 of the public members shall be individuals reasonably expected to qualify
2for coverage under the plan or the parent or spouse of such an individual. The
3commissioner secretary or the
commissioner's secretary's representative shall be the
4chairperson of the board. Board members, except the commissioner or the
5commissioner's representative
and the secretary or the secretary's representative,
6shall be compensated at the rate of $50 per diem plus actual and necessary expenses.
SB77-SSA1, s. 4863
7Section
4863. 619.15 (2) of the statutes is renumbered 149.15 (2) and amended
8to read:
SB77-SSA1,1821,149
149.15
(2) Annually, the board shall make a report to the
members of the plan
10and to the chief clerk of each house of the legislature, for distribution to the 11appropriate standing committees under s. 13.172 (3)
,
and to the members of the plan 12summarizing the activities of the plan in the preceding calendar year. The annual
13report shall define the cost burden imposed by the plan on all policyholders in this
14state.
SB77-SSA1, s. 4864
15Section
4864. 619.15 (3) (intro.) of the statutes is renumbered 149.15 (3)
16(intro.) and amended to read:
SB77-SSA1,1821,1717
149.15
(3) (intro.) The board shall
do all of the following:
SB77-SSA1, s. 4865
18Section
4865. 619.15 (3) (a) of the statutes is renumbered 149.15 (3) (a).
SB77-SSA1, s. 4867c
20Section 4867c. 619.15 (3) (c) of the statutes is renumbered 149.15 (3) (c) and
21amended to read:
SB77-SSA1,1822,322
149.15
(3) (c) Collect assessments from all insurers to provide for claims paid
23under the plan and for administrative expenses incurred or estimated to be incurred
24during the period for which the assessment is made. The level of payments shall be
25established
by the board as provided under s. 149.143. Assessment of the insurers
1shall occur at the end of each calendar year or other fiscal year end established
by
2the board. Assessments are due and payable within 30 days of receipt by the insurer
3of the assessment notice.
SB77-SSA1, s. 4868
4Section
4868. 619.15 (3) (d) of the statutes is renumbered 149.15 (3) (d).
SB77-SSA1, s. 4869c
5Section 4869c. 619.15 (3) (e) of the statutes is renumbered 149.15 (3) (e) and
6amended to read:
SB77-SSA1,1822,127
149.15
(3) (e) Establish for payment of covered expenses, a payment rate that
8is 10% less than the charges approved by the
administering carrier plan
9administrator for reimbursement of covered expenses under s.
619.14 149.14 (3).
A
10provider of a covered service or article may not bill an eligible person who receives
11the service or article for any amount by which the charge is reduced under this
12paragraph.
SB77-SSA1,1822,1514
619.15
(3) (f) In consultation with the office and the department of health and
15family services, establish a choice of coverage under s. 619.146.
SB77-SSA1, s. 4869f
16Section 4869f. 619.15 (3) (f) of the statutes, as created by 1997 Wisconsin Act
17.... (this act), is renumbered 149.15 (3) (f) and amended to read:
SB77-SSA1,1822,2018
149.15
(3) (f) In consultation with the office
of the commissioner of insurance 19and the department
of health and family services, establish a choice of coverage
20under s.
619.146 149.146.
SB77-SSA1, s. 4870
21Section
4870. 619.15 (4) (intro.) of the statutes is renumbered 149.15 (4)
22(intro.) and amended to read:
SB77-SSA1,1822,2323
149.15
(4) (intro.) The board may
do any of the following:
SB77-SSA1, s. 4871
24Section
4871. 619.15 (4) (a) of the statutes is renumbered 149.15 (4) (a).
SB77-SSA1, s. 4872
25Section
4872. 619.15 (4) (b) of the statutes is renumbered 149.15 (4) (b).
SB77-SSA1, s. 4876
4Section
4876. 619.15 (5) of the statutes is renumbered 149.15 (5) and amended
5to read:
SB77-SSA1,1823,76
149.15
(5) The
commissioner department may, by rule, establish additional
7powers and duties of the board.
SB77-SSA1, s. 4877
8Section
4877. 619.15 (6) of the statutes is renumbered 149.15 (6) and amended
9to read:
SB77-SSA1,1823,1110
149.15
(6) If any provision of this
subchapter chapter conflicts with s. 625.11
11or 625.12, this
subchapter chapter prevails.
SB77-SSA1, s. 4882
16Section
4882. 619.16 (3) (a) of the statutes is renumbered 149.16 (3) (a) and
17amended to read:
SB77-SSA1,1823,1918
149.16
(3) (a) The
administering carrier plan administrator shall perform all
19eligibility and administrative claims payment functions relating to the plan.
SB77-SSA1, s. 4883
20Section
4883. 619.16 (3) (b) of the statutes is renumbered 149.16 (3) (b) and
21amended to read:
SB77-SSA1,1823,2422
149.16
(3) (b) The
administering carrier plan administrator shall establish a
23premium billing procedure for collection of premiums from insured persons. Billings
24shall be made on a periodic basis as determined by the
board department.
SB77-SSA1, s. 4884c
1Section 4884c. 619.16 (3) (c) of the statutes is renumbered 149.16 (3) (c), and
2149.16 (3) (c) (intro.), as renumbered, is amended to read: