AB100-engrossed,1558,1813
149.14
(4m) Payment is payment in full. Except for copayments, coinsurance
14or deductibles required or authorized under the plan, a provider of a covered service
15or article shall accept as payment in full for the covered service or article the payment
16rate determined under ss. 149.143, 149.144 and 149.15 (3) (e) and may not bill an
17eligible person who receives the service or article for any amount by which the charge
18for the service or article is reduced under s. 149.143, 149.144 or 149.15 (3) (e).
AB100-engrossed,1558,21
20149.143 Payment of plan costs. (1) The department shall pay or recover the
21operating and administrative costs of the plan as follows:
AB100-engrossed,1558,2222
(a) First from the appropriation under s. 20.435 (5) (af).
AB100-engrossed,1558,2323
(b) The remainder of the costs as follows:
AB100-engrossed,1558,2424
1. A total of 60% from the following sources, calculated as follows:
AB100-engrossed,1559,6
1a. First, from premiums from eligible persons with coverage under s. 149.14 set
2at 150% of the rate that a standard risk would be charged under an individual policy
3providing substantially the same coverage and deductibles as are provided under the
4plan, including amounts received for premium and deductible subsidies under ss.
520.435 (5) (ah) and 149.144, and from premiums collected from eligible persons with
6coverage under s. 149.146 set in accordance with s. 149.146 (2) (b).
AB100-engrossed,1559,87
b. Second, from the appropriation under s. 20.435 (5) (gh), to the extent that
8the amounts under subd. 1. a. are insufficient to pay 60% of plan costs.
AB100-engrossed,1559,169
c. Third, by increasing premiums from eligible persons with coverage under s.
10149.14 to more than 150% but not more than 200% of the rate that a standard risk
11would be charged under an individual policy providing substantially the same
12coverage and deductibles as are provided under the plan, including amounts received
13for premium and deductible subsidies under ss. 20.435 (5) (ah) and 149.144, and by
14increasing premiums from eligible persons with coverage under s. 149.146 in
15accordance with s. 149.146 (2) (b), to the extent that the amounts under subd. 1. a.
16and b. are insufficient to pay 60% of plan costs.
AB100-engrossed,1559,2117
d. Fourth, notwithstanding subd. 2., by increasing insurer assessments,
18excluding assessments under s. 149.144, and adjusting provider payment rates,
19excluding adjustments to those rates under ss. 149.144 and 149.15 (3) (e), in equal
20proportions and to the extent that the amounts under subd. 1. a. to c. are insufficient
21to pay 60% of plan costs.
AB100-engrossed,1559,2222
2. A total of 40% as follows:
AB100-engrossed,1559,2423
a. Fifty percent from insurer assessments, excluding assessments under s.
24149.144.
AB100-engrossed,1560,2
1b. Fifty percent from adjustments to provider payment rates, excluding
2adjustments to those rates under ss. 149.144 and 149.15 (3) (e).
AB100-engrossed,1560,6
3(2) (a) Prior to each plan year, the department shall estimate the operating and
4administrative costs of the plan and the costs of the premium reductions under s.
5149.165 and the deductible reductions under s. 149.14 (5) (a) for the new plan year
6and do all of the following:
AB100-engrossed,1560,137
1. a. Estimate the amount of enrollee premiums that would be received in the
8new plan year if the enrollee premiums were set at a level sufficient, when including
9amounts received for premium and deductible subsidies under ss. 20.435 (5) (ah) and
10149.144 and from premiums collected from eligible persons with coverage under s.
11149.146 set in accordance with s. 149.146 (2) (b), to cover 60% of the estimated plan
12costs for the new plan year, after deducting from the estimated plan costs the amount
13available in the appropriation under s. 20.435 (5) (af) for that plan year.
AB100-engrossed,1560,1514
b. Estimate the amount of enrollee premiums that will be received under sub.
15(1) (b) 1. a.
AB100-engrossed,1560,2116
c. If the amount estimated to be received under subd. 1. a. is less than the
17amount estimated to be received under subd. 1. b., direct the plan administrator to
18provide to the department, prior to the beginning of the plan year and according to
19procedures specified by the department, the amount of the difference. The
20department shall deposit all amounts received under this subd. 1. c. in the
21appropriation account under s. 20.435 (5) (gh).
AB100-engrossed,1561,222
2. After making the determinations under subd. 1., by rule set premium rates
23for the new plan year, including the rates under s. 149.146 (2) (b), in the manner
24specified in sub. (1) (b) 1. a. and c. and such that a rate for coverage under s. 149.14
25is not less than 150% nor more than 200% of the rate that a standard risk would be
1charged under an individual policy providing substantially the same coverage and
2deductibles as are provided under the plan.
AB100-engrossed,1561,63
3. By rule set the total insurer assessments under s. 149.13 for the new plan
4year by estimating and setting the assessments at the amount necessary to equal the
5amounts specified in sub. (1) (b) 1. d. and 2. a. and notify the commissioner of the
6amount.
AB100-engrossed,1561,97
4. By the same rule as under subd. 3. adjust the provider payment rate for the
8new plan year by estimating and setting the rate at the level necessary to equal the
9amounts specified in sub. (1) (b) 1. d. and 2. b. and as provided in s. 149.145.
AB100-engrossed,1561,1510
(b) In setting the premium rates under par. (a) 2., the insurer assessment
11amount under par. (a) 3. and the provider payment rate under par. (a) 4. for the new
12plan year, the department shall include any increase or decrease necessary to reflect
13the amount, if any, by which the rates and amount set under par. (a) for the current
14plan year differed from the rates and amount which would have equaled the amounts
15specified in sub. (1) (b) in the current plan year.
AB100-engrossed,1561,25
16(3) (a) If, during a plan year, the department determines that the amounts
17estimated to be received as a result of the rates and amount set under sub. (2) (a) 2.
18to 4. and any adjustments in insurer assessments and the provider payment rate
19under s. 149.144 will not be sufficient to cover plan costs, the department may by rule
20increase the premium rates set under sub. (2) (a) 2. for the remainder of the plan year,
21subject to s. 149.146 (2) (b) and the maximum specified in sub. (2) (a) 2., by rule
22increase the assessments set under sub. (2) (a) 3. for the remainder of the plan year,
23subject to sub. (1) (b) 2. a., and by the same rule under which assessments are
24increased adjust the provider payment rate set under sub. (2) (a) 4. for the remainder
25of the plan year, subject to sub. (1) (b) 2. b.
AB100-engrossed,1562,6
1(b) If, after increasing premium rates and insurer assessments and adjusting
2the provider payment rate under par. (a), the department determines that there will
3still be a deficit and that premium rates have been increased to the maximum extent
4allowable under par. (a), the department shall further adjust, in equal proportions,
5assessments set under sub. (2) (a) 3. and the provider payment rate set under sub.
6(2) (a) 4., without regard to sub. (1) (b) 2.
AB100-engrossed,1562,10
7(3m) Subject to s. 149.14 (4m), insurers and providers may recover in the
8normal course of their respective businesses without time limitation assessments or
9provider payment rate adjustments used to recoup any deficit incurred under the
10plan.
AB100-engrossed,1562,15
11(4) Using the procedure under s. 227.24, the department may promulgate rules
12under sub. (2) or (3) for the period before the effective date of any permanent rules
13promulgated under sub. (2) or (3), but not to exceed the period authorized under s.
14227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) and (3), the department is not
15required to make a finding of emergency.
AB100-engrossed,1562,20
16(5) Notwithstanding sub. (2) (a) (intro.), the department shall set premium
17rates, insurer assessments and provider payment rates for the period beginning on
18January 1, 1998, and ending on June 30, 1998, in the manner provided in subs. (1),
19(2) (a), (3) and (4). This subsection applies to policies in effect on January 1, 1998,
20as well as to policies issued or renewed on or after January 1, 1998.
AB100-engrossed,1563,6
22149.145 Program budget. The department, in consultation with the board,
23shall establish a program budget for each plan year. The program budget shall be
24based on the provider payment rates specified in s. 149.15 (3) (e) and in the most
25recent provider contracts that are in effect and on the funding sources specified in
1s. 149.143 (1), including the methodologies specified in ss. 149.143, 149.144 and
2149.146 for determining premium rates, insurer assessments and provider payment
3rates. Except as otherwise provided in s. 149.143 (3) (a) and (b), from the program
4budget the department shall derive the actual provider payment rate for a plan year
5that reflects the providers' proportional share of the plan costs, consistent with ss.
6149.143 and 149.144.
AB100-engrossed,1563,108
149.15
(2m) Annually, beginning in 1999, the board shall submit a report on
9or before June 30 to the legislature under s. 13.172 (2) and to the governor on the
10operation of the plan, including any recommendations for changes to the plan.
AB100-engrossed,1563,1212
149.15
(3) (f) Advise the department on the choice of coverage under s. 149.146.
AB100-engrossed,1563,14
14149.16 (title)
Plan administrator.
AB100-engrossed,1563,1616
149.16
(1) The fiscal agent under s. 49.45 (2) (b) 2. shall administer the plan.
AB100-engrossed,1563,19
18149.20 Rule-making in consultation with board. In promulgating any
19rules under this chapter, the department shall consult with the board.
AB100-engrossed,1563,2121
150.21
(1) The construction
or total replacement of a
new nursing home.
AB100-engrossed,1563,2423
150.21
(3) A capital expenditure
, other than a renovation or replacement, that
24exceeds $1,000,000 by or on behalf of a nursing home.
AB100-engrossed,1564,2
1150.21
(4) An expenditure
, other than a renovation or replacement, that
2exceeds $600,000 for clinical equipment by or on behalf of a nursing home.
AB100-engrossed,1564,74
150.31
(4) The department may decrease the statewide bed limit in facilities
5primarily serving the developmentally disabled in order to account for any decreased
6use of beds at
the a state
centers center for the developmentally disabled due to the
7community integration program under s. 46.275.
AB100-engrossed,1564,119
150.31
(5t) The department shall decrease the statewide bed limits specified
10in sub. (1) to account for any reduction in the licensed bed capacity of a nursing home
11that has relinquished use of a bed, as specified in s. 49.45 (6m) (ap) 4.
AB100-engrossed,1564,1613
150.35
(3m) (a) 3. All applications for activities that are specified in s. 150.21
14(3)
, that are renovations with capital expenditures which do not exceed $1,500,000
15and that do not include additions, the replacement of a nursing home or an increase
16in the bed capacity of a nursing home.
AB100-engrossed,1564,2118
150.39
(2) The cost of
renovating or providing an equal number of nursing home
19beds or of an equal expansion would be consistent with the cost at similar nursing
20homes, and the applicant's per diem rates would be consistent with those of similar
21nursing homes.
AB100-engrossed,1564,2323
153.01
(4) "Department" means the department of health and family services.
AB100-engrossed,1565,62
153.05
(1) (c) 1. Identification of charges in each hospital's most recent entire
3fiscal year for up to 100 charge elements, as selected by the
office department, and
4identification of the increase or decrease in charges for each of these charge elements
5from amounts charged during the hospital's entire fiscal year that is nearest in time
6to the hospital's most recent entire fiscal year.
AB100-engrossed,1565,118
153.05
(1) (e) Final audited financial statements of hospitals that include, for
9a hospital's most recent entire fiscal year, as dollar amounts, the amounts of revenue
10and expenditures for the hospital, in categories specified in rules promulgated by the
11commissioner department.
AB100-engrossed,1565,1913
153.05
(2) The
office department shall provide copies of reports published
14under ss. 153.10 to 153.35 at no charge to hospitals assessed under s. 153.60 (1) and,
15if assessed, at no charge to ambulatory surgery centers assessed under s. 153.60 (2).
16The
office department shall provide copies of the reports to any person, upon the
17person's request, and the board shall advise the
office department as to whether the
18copies shall be provided at no charge or at a charge not to exceed the cost of printing,
19copying and mailing the report to the person.
AB100-engrossed,1565,2321
153.05
(3) Upon request of the
office
department, state agencies shall provide
22health care information to the
office department for use in preparing reports under
23ss. 153.10 to 153.35.
AB100-engrossed,1566,7
1153.05
(4) (a) The
office
department, under rules promulgated by the
2commissioner department, shall require hospitals to use, and private-pay patients
3and payers who are insurers to accept, uniform patient billing forms, shall require
4hospitals to submit to the
office department the information provided on the billing
5forms, including, for an injury, the external cause of the event, and may require
6payers who are insurers to use a standard set of definitions for base data reporting
7under a uniform patient billing form.
AB100-engrossed,1566,138
(b) The
office department, under rules promulgated by the
commissioner 9department, may require ambulatory surgery centers to use uniform patient billing
10forms and other information, and, if so requiring, shall require ambulatory surgery
11centers to submit to the
office department the information provided on the billing
12forms, including, for an injury, the external cause of the event, using a standard set
13of definitions for base data reporting.
AB100-engrossed,1566,1515
153.05
(5) The
office department:
AB100-engrossed,1566,1816
(a) Shall require hospitals to submit information regarding medical
17malpractice, staffing levels and patient case-mix, and expenditures related to labor
18relations consultants, as specified by the
office
department.
AB100-engrossed,1566,2319
(b) May require hospitals to submit to the
office
department information from
20sources identified under sub. (1) (a) to (e) that the
office department deems necessary
21for the preparation of reports, plans and recommendations under ss. 153.10 to 153.35
22and any other reports required of the
office department in the form specified by the
23office department.
AB100-engrossed,1567,224
(bm) Shall require a hospital to submit to the
office
department information
25from sources identified under sub. (1) (e) by the date that is 4 months following the
1close of the hospital's fiscal year unless the
office department grants an extension of
2time to file the information.
AB100-engrossed,1567,94
153.05
(6) If the requirements of s. 153.07 (2) are first met, the
office 5department may contract with a public or private entity that is not a major
6purchaser, payer or provider of health care services in this state for the provision of
7data processing services for the collection, analysis and dissemination of health care
8information under sub. (1) or the department
of health and family services shall
9provide the services under s. 153.07 (2).
AB100-engrossed,1567,1811
153.05
(6m) If the requirements of s. 153.07 (2) are first met, the
office 12department may contract with the group insurance board for the provision of data
13collection and analysis services related to health maintenance organizations and
14insurance companies that provide health insurance for state employes or the
15commissioner department shall provide the services under s. 153.07 (2). The
office 16department shall establish contract fees for the provision of the services. All moneys
17collected under this subsection shall be credited to the appropriation under s.
20.145
18(8) 20.435 (1) (kx).
AB100-engrossed,1567,2320
153.05
(7) The
office department may require each insurer authorized to write
21disability insurance to submit to the
office department information obtained on
22uniform patient billing forms regarding reported claims for health care services
23which insureds who are residents of this state obtain in another state.
AB100-engrossed,1568,9
1153.05
(8) Beginning April 1, 1992, the
office department shall collect, analyze
2and disseminate, in language that is understandable to lay persons, health care
3information under the provisions of this chapter, as determined by rules
4promulgated by the
commissioner department, from health care providers, as
5defined by rules promulgated by the
commissioner
department, other than hospitals
6and ambulatory surgery centers. Data from physicians shall be obtained through
7sampling techniques in lieu of collection of data on all patient encounters and data
8collection procedures shall minimize unnecessary duplication and administrative
9burdens.
AB100-engrossed,1568,1411
153.05
(9) The
office department shall provide orientation and training to
12physicians, hospital personnel and other health care providers to explain the process
13of data collection and analysis and the procedures for data verification,
14interpretation and release.
AB100-engrossed,1568,1916
153.05
(11) In order to elicit public comment concerning the reports required
17under ss. 153.10 to 153.35, the
office department shall, following the release of the
18reports and by a date that is determined by the board
, provide notice of and hold
19public hearings.
AB100-engrossed,1568,2321
153.05
(12) The
office department shall, to the extent possible and upon
22request, assist members of the public in interpreting data in health care information
23disseminated by the
office department.
AB100-engrossed,1569,3
1153.07
(1) The board shall advise the director of the
office department with
2regard to the collection, analysis and dissemination of health care information
3required by this chapter.