AB100: Bill Text Engrossed

AB100-engrossed,1556,10 Chapter 149

AB100-engrossed,1556,12 Mandatory health insurance risk-sharing plan

AB100-engrossed, s. 3014 Section 3014. 149.10 (2f) of the statutes is created to read:

AB100-engrossed,1556,14 149.10 (2f) "Commissioner" means the commissioner of insurance.

AB100-engrossed, s. 3015 Section 3015. 149.10 (2m) of the statutes is created to read:

AB100-engrossed,1556,17 149.10 (2m) "Department" means the department of health and family services.

AB100-engrossed, s. 3016 Section 3016. 149.10 (4c) of the statutes is created to read:

AB100-engrossed,1556,20 149.10 (4c) "Health maintenance organization" has the meaning given in s. 609.01 (2).

AB100-engrossed, s. 3017 Section 3017. 149.10 (4p) of the statutes is created to read:

AB100-engrossed,1556,22 149.10 (4p) (a) "Insurance" includes any of the following:

AB100-engrossed,1556,25 1. Risk distributing arrangements providing for compensation of damages or loss through the provision of services or benefits in kind rather than indemnity in money.

AB100-engrossed,1557,2 2. Contracts of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction.

AB100-engrossed,1557,3 3. Plans established and operated under ss. 185.981 to 185.985.

AB100-engrossed,1557,5 (b) "Insurance" does not include a continuing care contract, as defined in s. 647.01 (2).

AB100-engrossed, s. 3018 Section 3018. 149.10 (5m) of the statutes is created to read:

AB100-engrossed,1557,8 149.10 (5m) "Limited service health organization" has the meaning given in s. 609.01 (3).

AB100-engrossed, s. 3019c Section 3019c. 149.10 (8b) of the statutes is created to read:

AB100-engrossed,1557,11 149.10 (8b) "Plan administrator" means the fiscal agent specified in s. 149.16 (1).

AB100-engrossed, s. 3020 Section 3020. 149.10 (8c) of the statutes is created to read:

AB100-engrossed,1557,15 149.10 (8c) "Policy" means any document other than a group certificate used to prescribe in writing the terms of an insurance contract, including endorsements and riders and service contracts issued by motor clubs.

AB100-engrossed, s. 3020p Section 3020p. 149.10 (8j) of the statutes is created to read:

AB100-engrossed,1557,21 149.10 (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-engrossed, s. 3021 Section 3021. 149.10 (8m) of the statutes is created to read:

AB100-engrossed,1557,23 149.10 (8m) "Preferred provider plan" has the meaning given in s. 609.01 (4).

AB100-engrossed, s. 3022 Section 3022. 149.10 (8p) of the statutes is created to read:

AB100-engrossed,1558,3 149.10 (8p) "Premium" means any consideration for an insurance policy, and includes assessments, membership fees or other required contributions or consideration, however designated.

AB100-engrossed, s. 3023 Section 3023. 149.10 (10) of the statutes is created to read:

AB100-engrossed,1558,5 149.10 (10) "Secretary" means the secretary of health and family services.

AB100-engrossed, s. 3024 Section 3024. 149.10 (11) of the statutes is created to read:

AB100-engrossed,1558,8 149.10 (11) "State" means the same as in s. 990.01 (40) except that it also includes the Panama Canal Zone.

AB100-engrossed, s. 3025f Section 3025f. 149.12 (2) (f) of the statutes is created to read:

AB100-engrossed,1558,11 149.12 (2) (f) No person who is eligible for medical assistance is eligible for coverage under the plan.

AB100-engrossed, s. 3026c Section 3026c. 149.14 (4m) of the statutes is created to read:

AB100-engrossed,1558,18 149.14 (4m) Payment is payment in full. Except for copayments, coinsurance or deductibles required or authorized under the plan, a provider of a covered service or article shall accept as payment in full for the covered service or article the payment rate determined under ss. 149.143, 149.144 and 149.15 (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. 149.143, 149.144 or 149.15 (3) (e).

AB100-engrossed, s. 3026f Section 3026f. 149.143 of the statutes is created to read:

AB100-engrossed,1558,21 149.143 Payment of plan costs. (1) The department shall pay or recover the operating and administrative costs of the plan as follows:

AB100-engrossed,1558,22 (a) First from the appropriation under s. 20.435 (5) (af).

AB100-engrossed,1558,23 (b) The remainder of the costs as follows:

AB100-engrossed,1558,24 1. A total of 60% from the following sources, calculated as follows:

AB100-engrossed,1559,6 a. First, from premiums from eligible persons with coverage under s. 149.14 set at 150% 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, including amounts received for premium and deductible subsidies under ss. 20.435 (5) (ah) and 149.144, and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).

AB100-engrossed,1559,8 b. Second, from the appropriation under s. 20.435 (5) (gh), to the extent that the amounts under subd. 1. a. are insufficient to pay 60% of plan costs.

AB100-engrossed,1559,16 c. Third, by increasing premiums from eligible persons with coverage under s. 149.14 to more than 150% but not more than 200% 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, including amounts received for premium and deductible subsidies under ss. 20.435 (5) (ah) and 149.144, and by increasing premiums from eligible persons with coverage under s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under subd. 1. a. and b. are insufficient to pay 60% of plan costs.

AB100-engrossed,1559,21 d. Fourth, notwithstanding subd. 2., by increasing insurer assessments, excluding assessments under s. 149.144, and adjusting provider payment rates, excluding adjustments to those rates under ss. 149.144 and 149.15 (3) (e), in equal proportions and to the extent that the amounts under subd. 1. a. to c. are insufficient to pay 60% of plan costs.

AB100-engrossed,1559,22 2. A total of 40% as follows:

AB100-engrossed,1559,24 a. Fifty percent from insurer assessments, excluding assessments under s. 149.144.

AB100-engrossed,1560,2 b. Fifty percent from adjustments to provider payment rates, excluding adjustments to those rates under ss. 149.144 and 149.15 (3) (e).

AB100-engrossed,1560,6 (2) (a) Prior to each plan year, the department shall estimate the operating and administrative costs of the plan and the costs of the premium reductions under s. 149.165 and the deductible reductions under s. 149.14 (5) (a) for the new plan year and do all of the following:

AB100-engrossed,1560,13 1. a. Estimate the amount of enrollee premiums that would be received in the new plan year if the enrollee premiums were set at a level sufficient, when including amounts received for premium and deductible subsidies under ss. 20.435 (5) (ah) and 149.144 and from premiums collected from eligible persons with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60% of the estimated plan costs for the new plan year, after deducting from the estimated plan costs the amount available in the appropriation under s. 20.435 (5) (af) for that plan year.

AB100-engrossed,1560,15 b. Estimate the amount of enrollee premiums that will be received under sub. (1) (b) 1. a.

AB100-engrossed,1560,21 c. If the amount estimated to be received under subd. 1. a. is less than the amount estimated to be received under subd. 1. b., direct the plan administrator to provide to the department, prior to the beginning of the plan year and according to procedures specified by the department, the amount of the difference. The department shall deposit all amounts received under this subd. 1. c. in the appropriation account under s. 20.435 (5) (gh).

AB100-engrossed,1561,2 2. After making the determinations under subd. 1., by rule set premium rates for the new plan year, including the rates under s. 149.146 (2) (b), in the manner specified in sub. (1) (b) 1. a. and c. and such that a rate for coverage under s. 149.14 is not less than 150% nor more than 200% 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-engrossed,1561,6 3. By rule set the total insurer assessments under s. 149.13 for the new plan year by estimating and setting the assessments at the amount necessary to equal the amounts specified in sub. (1) (b) 1. d. and 2. a. and notify the commissioner of the amount.

AB100-engrossed,1561,9 4. By the same rule as under subd. 3. adjust the provider payment rate for the new plan year by estimating and setting the rate at the level necessary to equal the amounts specified in sub. (1) (b) 1. d. and 2. b. and as provided in s. 149.145.

AB100-engrossed,1561,15 (b) In setting the premium rates under par. (a) 2., the insurer assessment amount under par. (a) 3. and the provider payment rate under par. (a) 4. for the new plan year, the department 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) (b) in the current plan year.

AB100-engrossed,1561,25 (3) (a) If, during a plan year, the department determines that the amounts estimated to be received as a result of the rates and amount set under sub. (2) (a) 2. to 4. and any adjustments in insurer assessments and the provider payment rate under s. 149.144 will not be sufficient to cover plan costs, the department may by rule increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year, subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year, subject to sub. (1) (b) 2. a., and by the same rule under which assessments are increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder of the plan year, subject to sub. (1) (b) 2. b.

AB100-engrossed,1562,6 (b) If, after increasing premium rates and insurer assessments and adjusting the provider payment rate under par. (a), the department determines that there will still be a deficit and that premium rates have been increased to the maximum extent allowable under par. (a), the department shall further adjust, in equal proportions, assessments set under sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard to sub. (1) (b) 2.

AB100-engrossed,1562,10 (3m) Subject to s. 149.14 (4m), insurers and providers may recover in the normal course of their respective businesses without time limitation assessments or provider payment rate adjustments used to recoup any deficit incurred under the plan.

AB100-engrossed,1562,15 (4) Using the procedure under s. 227.24, the department 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 department is not required to make a finding of emergency.

AB100-engrossed,1562,20 (5) Notwithstanding sub. (2) (a) (intro.), the department shall set premium rates, insurer assessments and provider payment 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-engrossed, s. 3026p Section 3026p. 149.145 of the statutes is created to read:

AB100-engrossed,1563,6 149.145 Program budget. The department, in consultation with the board, shall establish a program budget for each plan year. The program budget shall be based on the provider payment rates specified in s. 149.15 (3) (e) and in the most recent provider contracts that are in effect and on the funding sources specified in s. 149.143 (1), including the methodologies specified in ss. 149.143, 149.144 and 149.146 for determining premium rates, insurer assessments and provider payment rates. Except as otherwise provided in s. 149.143 (3) (a) and (b), from the program budget the department shall derive the actual provider payment rate for a plan year that reflects the providers' proportional share of the plan costs, consistent with ss. 149.143 and 149.144.

AB100-engrossed, s. 3027m Section 3027m. 149.15 (2m) of the statutes is created to read:

AB100-engrossed,1563,10 149.15 (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-engrossed, s. 3027r Section 3027r. 149.15 (3) (f) of the statutes is created to read:

AB100-engrossed,1563,12 149.15 (3) (f) Advise the department on the choice of coverage under s. 149.146.

AB100-engrossed, s. 3030 Section 3030. 149.16 (title) of the statutes is created to read:

AB100-engrossed,1563,14 149.16 (title) Plan administrator.

AB100-engrossed, s. 3031 Section 3031. 149.16 (1) of the statutes is created to read:

AB100-engrossed,1563,16 149.16 (1) The fiscal agent under s. 49.45 (2) (b) 2. shall administer the plan.

AB100-engrossed, s. 3031m Section 3031m. 149.20 of the statutes is created to read:

AB100-engrossed,1563,19 149.20 Rule-making in consultation with board. In promulgating any rules under this chapter, the department shall consult with the board.

AB100-engrossed, s. 3033 Section 3033. 150.21 (1) of the statutes is amended to read:

AB100-engrossed,1563,21 150.21 (1) The construction or total replacement of a new nursing home.

AB100-engrossed, s. 3034 Section 3034. 150.21 (3) of the statutes is amended to read:

AB100-engrossed,1563,24 150.21 (3) A capital expenditure, other than a renovation or replacement, that exceeds $1,000,000 by or on behalf of a nursing home.

AB100-engrossed, s. 3035 Section 3035. 150.21 (4) of the statutes is amended to read:

AB100-engrossed,1564,2 150.21 (4) An expenditure, other than a renovation or replacement, that exceeds $600,000 for clinical equipment by or on behalf of a nursing home.

AB100-engrossed, s. 3035v Section 3035v. 150.31 (4) of the statutes is amended to read:

AB100-engrossed,1564,7 150.31 (4) The department may decrease the statewide bed limit in facilities primarily serving the developmentally disabled in order to account for any decreased use of beds at the a state centers center for the developmentally disabled due to the community integration program under s. 46.275.

AB100-engrossed, s. 3036 Section 3036. 150.31 (5t) of the statutes is created to read:

AB100-engrossed,1564,11 150.31 (5t) The department shall decrease the statewide bed limits specified in sub. (1) to account for any reduction in the licensed bed capacity of a nursing home that has relinquished use of a bed, as specified in s. 49.45 (6m) (ap) 4.

AB100-engrossed, s. 3037 Section 3037. 150.35 (3m) (a) 3. of the statutes is amended to read:

AB100-engrossed,1564,16 150.35 (3m) (a) 3. All applications for activities that are specified in s. 150.21 (3), that are renovations with capital expenditures which do not exceed $1,500,000 and that do not include additions, the replacement of a nursing home or an increase in the bed capacity of a nursing home.

AB100-engrossed, s. 3038 Section 3038. 150.39 (2) of the statutes is amended to read:

AB100-engrossed,1564,21 150.39 (2) The cost of renovating or providing an equal number of nursing home beds or of an equal expansion would be consistent with the cost at similar nursing homes, and the applicant's per diem rates would be consistent with those of similar nursing homes.

AB100-engrossed, s. 3041 Section 3041. 153.01 (4) of the statutes is created to read:

AB100-engrossed,1564,23 153.01 (4) "Department" means the department of health and family services.

AB100-engrossed, s. 3042 Section 3042. 153.01 (4m) of the statutes is repealed.

AB100-engrossed, s. 3043 Section 3043. 153.01 (6) of the statutes is repealed.