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:
SB77-SSA1,1824,53
149.16
(3) (c) (intro.) The
administering carrier plan administrator shall
4perform all necessary functions to assure timely payment of benefits to covered
5persons under the plan, including:
SB77-SSA1, s. 4886
7Section
4886. 619.16 (3) (e) of the statutes is renumbered 149.16 (3) (e) and
8amended to read:
SB77-SSA1,1824,169
149.16
(3) (e) The
administering carrier plan administrator, under the
10direction of the department, shall pay claims expenses from the premium payments
11received from or on behalf of covered persons under the plan. If the
administering
12carrier's plan administrator's payments for claims expenses exceed
the portion of
13premiums allocated by the board for payment of claims expenses
premium
14payments, the board
shall forward to the department, and the department shall
15provide to the
carrier plan administrator, additional funds for payment of claims
16expenses.
SB77-SSA1, s. 4889
19Section
4889. 619.165 (title) of the statutes is renumbered 149.165 (title).
SB77-SSA1, s. 4890
20Section
4890. 619.165 (1) (a) of the statutes is renumbered 149.165 (1) and
21amended to read:
SB77-SSA1,1824,2522
149.165
(1) The board Except as provided in s. 149.146 (2) (a), the department 23shall reduce the premiums established
by the commissioner under s.
619.11 149.11 24in conformity with ss.
619.14 (5) 149.143 and
619.17 149.17, for the eligible persons
25and in the manner set forth in
pars. (b) to (d) subs. (2) and (3).
SB77-SSA1, s. 4891
1Section
4891. 619.165 (1) (b) of the statutes is renumbered 149.165 (2), and
2149.165 (2) (intro.), as renumbered, is amended to read:
SB77-SSA1,1825,73
149.165
(2) (intro.) If the household income, as defined in s. 71.52 (5) and as
4determined under
par. (d) sub. (3), of an eligible person is equal to or greater than
5the first amount and less than the 2nd amount listed in any of the following, the
6board department shall reduce the premium for the eligible person
, as established
7by the commissioner, to the rate shown after the amounts:
SB77-SSA1, s. 4892
8Section
4892. 619.165 (1) (d) of the statutes is renumbered 149.165 (3) and
9amended to read:
SB77-SSA1,1825,1110
149.165
(3) The
board department shall establish and implement the method
11for determining the household income of an eligible person under
par. (b) sub. (2).
SB77-SSA1, s. 4894
13Section
4894. 619.165 (3) of the statutes is renumbered 149.165 (4) and
14amended to read:
SB77-SSA1,1825,1815
149.165
(4) The
commissioner shall forward to the board moneys received
16under s. 20.145 (7) (a) and (g) in an amount sufficient to department shall reimburse
17the plan for premium reductions under sub.
(1) (2) and deductible reductions under
18s.
619.14 149.14 (5) (a)
with moneys from the appropriation under s. 20.435 (5) (ah).
SB77-SSA1, s. 4896
20Section
4896. 619.17 (intro.) of the statutes is renumbered 149.17 (intro.).
SB77-SSA1, s. 4897
21Section
4897. 619.17 (1) of the statutes is renumbered 149.17 (1) and amended
22to read:
SB77-SSA1,1825,2423
149.17
(1) Subject to
s. 619.14 (5) (a) ss. 149.143 and 149.146 (2) (b), a rating
24plan calculated in accordance with generally accepted actuarial principles.
SB77-SSA1, s. 4898
1Section
4898. 619.17 (2) of the statutes is renumbered 149.17 (2) and amended
2to read:
SB77-SSA1,1826,43
149.17
(2) A schedule of premiums, deductibles and coinsurance payments
4which complies with all requirements of this
subchapter chapter.
SB77-SSA1, s. 4900
6Section
4900. 619.17 (4) (a) of the statutes is renumbered 149.17 (4) and
7amended to read:
SB77-SSA1,1826,98
149.17
(4) Cost containment provisions established by the
commissioner 9department by rule
, including managed care requirements.
SB77-SSA1, s. 4901
10Section
4901. 619.175 of the statutes is renumbered 149.175 and amended to
11read:
SB77-SSA1,1826,16
12149.175 Waiver or exemption from provisions prohibited. Except as
13provided in s.
619.13 (1) (a) 149.13 (1), the
commissioner department may not waive,
14or authorize the board to waive, any of the requirements of this
subchapter chapter 15or exempt, or authorize the board to exempt, an individual or a class of individuals
16from any of the requirements of this
subchapter chapter.
SB77-SSA1, s. 4902
17Section
4902. 619.18 of the statutes is renumbered 149.18 and amended to
18read:
SB77-SSA1,1826,21
19149.18 Chapters 600 to 645 applicable. Except as otherwise provided in this
20subchapter chapter, the plan shall comply and be administered in compliance with
21chs. 600 to 645.
SB77-SSA1,1827,223
631.36
(7) (a) 2. Unless the notice contains adequate instructions to the
24policyholder for applying for insurance through a risk-sharing plan under
subch. I
1of ch. 619, if a risk-sharing plan exists under
subch. I of ch. 619 for the kind of
2coverage being canceled or nonrenewed, except as provided in par. (b).
SB77-SSA1,1827,135
632.745
(1) (d) "Health benefit plan" means any hospital or medical policy or
6certificate. "Health benefit plan" does not include accident-only, credit accident or
7health, dental, vision, medicare supplement, medicare replacement, long-term care,
8disability income or short-term insurance, coverage issued as a supplement to
9liability insurance, worker's compensation or similar insurance, automobile medical
10payment insurance, individual conversion policies, specified disease policies,
11hospital indemnity policies, as defined in s. 632.895 (1) (c), policies or certificates
12issued under the health insurance risk-sharing plan
or an alternative plan under
13subch. II of ch.
619 149 or other insurance exempted by rule of the commissioner.
SB77-SSA1,1827,2216
632.745
(1) (f) 2. Notwithstanding subd. 1. b. and c., "qualifying coverage" does
17not include a high cost-share health plan, as defined in s. 632.898 (1) (c),
1995 stats., 18that is linked to a medical savings account, as described in s. 632.898,
1995 stats., 19if the employer that provides the individual's new coverage offers its eligible
20employes a choice of health benefit plan options that includes a high cost-share
21health plan, as defined in s. 632.898 (1) (c),
1995 stats., and the individual's new
22coverage is not a high cost-share health plan.
SB77-SSA1, s. 4930
23Section
4930. 632.785 (1) (intro.) of the statutes is amended to read:
SB77-SSA1,1828,524
632.785
(1) (intro.) If an insurer issues one or more of the following or takes any
25other action based wholly or partially on medical underwriting considerations which
1is likely to render any person eligible under s.
619.12 149.12 for coverage under
2subch. II of ch.
619 149, the insurer shall notify all persons affected of the existence
3of the mandatory health insurance risk-sharing plan under
subch. II of ch.
619 149,
4as well as the eligibility requirements and method of applying for coverage under the
5plan:
SB77-SSA1,1828,107
632.89
(2) (a) 2. Except as provided in pars. (b) to (e), coverage of conditions
8under subd. 1. by a policy may
not be subject to exclusions or limitations
, including
9deductibles, that are
not generally applicable to other conditions covered under the
10policy.
SB77-SSA1,1828,1212
632.89
(2) (c) 2. a. The expenses of
the first 30 days as an inpatient in a hospital.
SB77-SSA1,1828,1714
632.89
(2) (c) 2. b.
The first $7,000
Seven thousand dollars minus a copayment
15of up to 10% for inpatient hospital services or, if the coverage is provided by a health
16maintenance organization, as defined in s. 609.01 (2),
the first $6,300 or the
17equivalent benefits measured in services rendered.
SB77-SSA1,1828,2319
632.89
(2) (d) 2. Except as provided in par. (b), a policy under subd. 1. shall
20provide coverage in every policy year for not less than
the first $2,000 $7,000 minus
21a copayment of up to 10% for outpatient services or, if the coverage is provided by a
22health maintenance organization, as defined in s. 609.01 (2),
the first $1,800 $6,300 23or the equivalent benefits measured in services rendered.
SB77-SSA1,1829,5
1632.89
(2) (dm) 2. Except as provided in par. (b), a policy under subd. 1. shall
2provide coverage in every policy year for not less than
the first $3,000 $7,000 minus
3a copayment of up to 10% for transitional treatment arrangements or, if the coverage
4is provided by a health maintenance organization, as defined in s. 609.01 (2),
the first
5$2,700 $6,300 or the equivalent benefits measured in services rendered.
SB77-SSA1,1829,147
632.895
(11) Procedures involving a bone, joint, muscle or tissue and
8intraoral splint therapy devices. (a) Every disability insurance policy, and every
9self-insured health plan of the state or a county, city, village, town or school district,
10that provides coverage of any diagnostic or surgical procedure involving a bone, joint,
11muscle or tissue shall provide coverage for diagnostic and surgical procedures
12involving a bone, joint, muscle or tissue of the face, neck, head or skeletal structure,
13and for prescribed intraoral splint therapy devices, for the treatment of a condition,
14if all of the following apply:
SB77-SSA1,1829,1615
1. The condition is caused by congenital, developmental or acquired deformity,
16disease or injury.