SB45-SSA1,1159,75 149.12 (2) (d) 1. Except for a person who is an eligible individual as provided
6in subd. 2.
, no person who is 65 years of age or older is eligible for coverage under the
7plan.
SB45-SSA1, s. 2257 8Section 2257. 149.12 (2) (d) 2. of the statutes is created to read:
SB45-SSA1,1159,99 149.12 (2) (d) 2. Subdivision 1. does not apply to any of the following:
SB45-SSA1,1159,1010 a. A person who is an eligible individual.
SB45-SSA1,1159,1211 b. A person who has coverage under the plan on the date on which he or she
12attains the age of 65 years.
SB45-SSA1, s. 2258 13Section 2258. 149.12 (3) (b) of the statutes is amended to read:
SB45-SSA1,1159,1914 149.12 (3) (b) Persons for whom deductible or coinsurance amounts are paid
15or reimbursed under ch. 47 for vocational rehabilitation, under s. 49.68 for renal
16disease, under s. 49.685 (8) for hemophilia, under s. 49.683 for cystic fibrosis or,
17under s. 253.05 for maternal and child health services or under s. 49.686 for the cost
18of drugs for the treatment of HIV infection or AIDS
are not ineligible for coverage
19under the plan by reason of such payments or reimbursements.
SB45-SSA1, s. 2258d 20Section 2258d. 149.125 of the statutes is repealed.
SB45-SSA1, s. 2258f 21Section 2258f. 149.14 (2) (a) of the statutes is amended to read:
SB45-SSA1,1160,322 149.14 (2) (a) The plan shall provide every eligible person who is not eligible
23for medicare with major medical expense coverage. Major medical expense coverage
24offered under the plan under this section shall pay an eligible person's covered
25expenses, subject to sub. (3) and deductible, copayment and coinsurance payments

1authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered individual.
2The maximum limit under this paragraph shall not be altered by the board, and no
3actuarially equivalent benefit may be substituted by the board.
SB45-SSA1, s. 2259 4Section 2259. 149.14 (3) (intro.) of the statutes is amended to read:
SB45-SSA1,1160,195 149.14 (3) Covered expenses. (intro.) Except as provided in sub. (4), except
6as
restricted by cost containment provisions under s. 149.17 (4) and except as
7reduced by the board under s. 149.15 (3) (e) or by the department under s. ss. 149.143
8or and 149.144, covered expenses for the coverage under this section shall be the
9usual and customary charges payment rates established by the department under
10s. 149.142
for the services provided by persons licensed under ch. 446 and certified
11under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost
12containment provisions under s. 149.17 (4) and except as reduced by the board under
13s. 149.15 (3) (e) or by the
department under s. ss. 149.143 or and 149.144, covered
14expenses for the coverage under this section shall also be the usual and customary
15charges
payment rates established by the department under s. 149.142 for the
16following services and articles if the service or article is prescribed by a physician
17who is licensed under ch. 448 or in another state and who is certified under s. 49.45
18(2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45
19(2) (a) 11.:
SB45-SSA1, s. 2259f 20Section 2259f. 149.14 (3) (d) of the statutes is amended to read:
SB45-SSA1,1160,2121 149.14 (3) (d) Drugs requiring a physician's prescription, subject to sub. (4c).
SB45-SSA1, s. 2259r 22Section 2259r. 149.14 (4) (d) of the statutes is amended to read:
SB45-SSA1,1161,223 149.14 (4) (d) That part of any charge for services or articles rendered or
24prescribed by a physician, dentist or other health care personnel which that exceeds
25the prevailing charge in the locality where the service is provided payment rate

1established by the department under s. 149.142 and reduced under ss. 149.143 and
2149.144
or any charge not medically necessary.
SB45-SSA1, s. 2260 3Section 2260. 149.14 (4) (g) of the statutes is amended to read:
SB45-SSA1,1161,44 149.14 (4) (g) Dental care except as provided in sub. (3) (m) and (q).
SB45-SSA1, s. 2260c 5Section 2260c. 149.14 (4) (n) of the statutes is created to read:
SB45-SSA1,1161,76 149.14 (4) (n) Services or drugs for the treatment of infertility, impotence or
7sterility.
SB45-SSA1, s. 2260d 8Section 2260d. 149.14 (4c) of the statutes is created to read:
SB45-SSA1,1161,119 149.14 (4c) Coverage of prescription drugs. (a) The department may require
10a pharmacist or pharmacy that provides a prescription drug to an eligible person to
11submit a payment claim directly to the plan administrator.
SB45-SSA1,1161,1412 (b) The department may limit coverage of prescription drugs under sub. (3) (d)
13to those prescription drugs for which payment claims are submitted by pharmacists
14or pharmacies directly to the plan administrator.
SB45-SSA1, s. 2260h 15Section 2260h. 149.14 (4m) of the statutes is amended to read:
SB45-SSA1,1161,2216 149.14 (4m) Payment is payment in full. Except for copayments, coinsurance
17or deductibles required or authorized under the plan, a provider of a covered service
18or article shall accept as payment in full for the covered service or article the payment
19rate determined under ss. 149.142, 149.143, and 149.144 and 149.15 (3) (e) and may
20not bill an eligible person who receives the service or article for any amount by which
21the charge for the service or article is reduced under s. 149.142, 149.143, or 149.144
22or 149.15 (3) (e).
SB45-SSA1, s. 2260m 23Section 2260m. 149.14 (5) (title) of the statutes is amended to read:
SB45-SSA1,1161,2424 149.14 (5) (title) Deductibles, copayments and coinsurance.
SB45-SSA1, s. 2260p 25Section 2260p. 149.14 (5) (e) of the statutes is created to read:
SB45-SSA1,1162,5
1149.14 (5) (e) Subject to sub. (8) (b), the department may, by rule under s. 149.17
2(4), establish copayments for prescription drug coverage under sub. (3) (d). Any
3copayment amounts or rates established are subject to the approval of the board.
4Copayments paid by an eligible person under this paragraph shall count toward the
5deductible and covered costs not paid by the plan under pars. (a) to (c).
SB45-SSA1, s. 2261 6Section 2261. 149.14 (6) (title) of the statutes is created to read:
SB45-SSA1,1162,77 149.14 (6) (title) Preexisting conditions.
SB45-SSA1, s. 2261f 8Section 2261f. 149.14 (8) of the statutes is created to read:
SB45-SSA1,1162,129 149.14 (8) Applicability of medical assistance provisions. (a) Except as
10provided in par. (b), the department may, by rule under s. 149.17 (4), apply to the plan
11the same utilization and cost control procedures that apply under rules promulgated
12by the department to medical assistance under subch. IV of ch. 49.
SB45-SSA1,1162,1513 (b) The department may not apply to eligible persons for covered services or
14articles the same copayments that apply to recipients of medical assistance under
15subch. IV of ch. 49 for services or articles covered under that program.
SB45-SSA1, s. 2261j 16Section 2261j. 149.142 of the statutes is created to read:
SB45-SSA1,1162,25 17149.142 Provider payment rates. (1) (a) Except as provided in par. (b), the
18department shall establish payment rates for covered expenses that consist of the
19allowable charges paid under s. 49.46 (2) for the services and articles provided plus
20an enhancement determined by the department. The rates shall be based on the
21allowable charges paid under s. 49.46 (2), projected plan costs and trend factors.
22Using the same methodology that applies to medical assistance under subch. IV of
23ch. 49, the department shall establish hospital outpatient per visit reimbursement
24rates and hospital inpatient reimbursement rates that are specific to diagnostically
25related groups of eligible persons.
SB45-SSA1,1163,2
1(b) The payment rate for a prescription drug shall be the allowable charge paid
2under s. 49.46 (2) (b) 6. h. for the prescription drug.
SB45-SSA1,1163,4 3(2) The rates established under this section are subject to adjustment under
4ss. 149.143 and 149.144.
SB45-SSA1, s. 2261m 5Section 2261m. 149.143 (1) (intro.) of the statutes is amended to read:
SB45-SSA1,1163,116 149.143 (1) (intro.) The department shall pay or recover the operating costs of
7the plan from the appropriation under s. 20.435 (4) (v)
and administrative costs of
8the plan from the appropriation under s. 20.435 (4) (u). For purposes of determining
9premiums, insurer assessments and provider payment rate adjustments, the
10department shall apportion and prioritize responsibility for payment or recovery of
11plan costs from among the moneys constituting the fund
as follows:
SB45-SSA1, s. 2262b 12Section 2262b. 149.143 (1) (a) of the statutes is amended to read:
SB45-SSA1,1163,1413 149.143 (1) (a) First from the moneys transferred to the fund from the
14appropriation account under s. 20.435 (5) (4) (af).
SB45-SSA1, s. 2263b 15Section 2263b. 149.143 (1) (b) 1. a. of the statutes is amended to read:
SB45-SSA1,1163,2316 149.143 (1) (b) 1. a. First, from premiums from eligible persons with coverage
17under s. 149.14 set at 150% of the rate that a standard risk would be charged under
18an individual policy providing substantially the same coverage and deductibles as
19are provided under the plan, including amounts received for premium and deductible
20subsidies under s. 149.144 and under the transfer to the fund from the appropriation
21account
under ss. s. 20.435 (5) (4) (ah) and 149.144, and from premiums collected
22from eligible persons with coverage under s. 149.146 set in accordance with s.
23149.146 (2) (b).
SB45-SSA1, s. 2263bm 24Section 2263bm. 149.143 (1) (b) 1. b. of the statutes is amended to read:
SB45-SSA1,1164,3
1149.143 (1) (b) 1. b. Second, from the appropriation under s. 20.435 (5) (gh)
2moneys specified under sub. (2m), to the extent that the amounts under subd. 1. a.
3are insufficient to pay 60% of plan costs.
SB45-SSA1, s. 2263bn 4Section 2263bn. 149.143 (1) (b) 1. c. of the statutes is amended to read:
SB45-SSA1,1164,135 149.143 (1) (b) 1. c. Third, by increasing premiums from eligible persons with
6coverage under s. 149.14 to more than 150% but not more than 200% of the rate that
7a standard risk would be charged under an individual policy providing substantially
8the same coverage and deductibles as are provided under the plan, including
9amounts received for premium and deductible subsidies under s. 149.144 and under
10the transfer to the fund from the appropriation account
under ss. s. 20.435 (5) (4) (ah)
11and 149.144, and by increasing premiums from eligible persons with coverage under
12s. 149.146 in accordance with s. 149.146 (2) (b), to the extent that the amounts under
13subd. 1. a. and b. are insufficient to pay 60% of plan costs.
SB45-SSA1, s. 2263bp 14Section 2263bp. 149.143 (1) (b) 1. d. of the statutes is amended to read:
SB45-SSA1,1164,1915 149.143 (1) (b) 1. d. Fourth, notwithstanding subd. 2., by increasing insurer
16assessments, excluding assessments under s. 149.144, and adjusting provider
17payment rates, excluding adjustments to those rates under ss. s. 149.144 and 149.15
18(3) (e)
, in equal proportions and to the extent that the amounts under subd. 1. a. to
19c. are insufficient to pay 60% of plan costs.
SB45-SSA1, s. 2264e 20Section 2264e. 149.143 (1) (b) 2. b. of the statutes is amended to read:
SB45-SSA1,1164,2221 149.143 (1) (b) 2. b. Fifty percent from adjustments to provider payment rates,
22excluding adjustments to those rates under ss. s. 149.144 and 149.15 (3) (e).
SB45-SSA1, s. 2265b 23Section 2265b. 149.143 (2) (a) 1. a. of the statutes is amended to read:
SB45-SSA1,1165,724 149.143 (2) (a) 1. a. Estimate the amount of enrollee premiums that would be
25received in the new plan year if the enrollee premiums were set at a level sufficient,

1when including amounts received for premium and deductible subsidies under s.
2149.144 and under the transfer to the fund from the appropriation account
under ss.
3s. 20.435 (5) (4) (ah) and 149.144 and from premiums collected from eligible persons
4with coverage under s. 149.146 set in accordance with s. 149.146 (2) (b), to cover 60%
5of the estimated plan costs for the new plan year, after deducting from the estimated
6plan costs the amount available in for transfer to the fund from the appropriation
7account under s. 20.435 (5) (4) (af) for that plan year.
SB45-SSA1, s. 2265bm 8Section 2265bm. 149.143 (2) (a) 1. c. of the statutes is repealed.
SB45-SSA1, s. 2266g 9Section 2266g. 149.143 (2m) of the statutes is created to read:
SB45-SSA1,1165,1110 149.143 (2m) (a) The department shall keep a separate accounting of the
11difference between the following:
SB45-SSA1,1165,1312 1. The amount of premiums received in a plan year from all eligible persons,
13including amounts received for premium and deductible subsidies.
SB45-SSA1,1165,1714 2. The amount of premiums, including amounts received for premium and
15deductible subsidies, necessary to cover 60% of the plan costs for the plan year, after
16deducting the amount transferred to the fund from the appropriation account under
17s. 20.435 (4) (af).
SB45-SSA1,1165,1918 (b) Any amount by which the amount under par. (a) 1. exceeds the amount
19under par. (a) 2. may be used only as follows:
SB45-SSA1,1165,2420 1. To reduce premiums in succeeding plan years as provided in sub. (1) (b) 1.
21b. For eligible persons with coverage under s. 149.14, premiums may not be reduced
22below 150% of the rate that a standard risk would be charged under an individual
23policy providing substantially the same coverage and deductibles as are provided
24under the plan.
SB45-SSA1,1165,2525 2. For other needs of eligible persons, with the approval of the board.
SB45-SSA1, s. 2267j
1Section 2267j. 149.143 (3) (b) of the statutes is amended to read:
SB45-SSA1,1166,82 149.143 (3) (b) If, after increasing the department increases premium rates
3and insurer assessments and adjusting adjusts the provider payment rate under par.
4(a), the department and determines that there will still be a deficit and that premium
5rates have been increased to the maximum extent allowable under par. (a), the
6department shall may further adjust, in equal proportions, assessments set under
7sub. (2) (a) 3. and the provider payment rate set under sub. (2) (a) 4., without regard
8to sub. (1) (b) 2.
SB45-SSA1, s. 2267m 9Section 2267m. 149.143 (5) of the statutes is created to read:
SB45-SSA1,1166,1610 149.143 (5) (a) Annually, no later than April 30, the department shall perform
11a reconciliation with respect to plan costs, premiums, insurer assessments and
12provider payment rate adjustments based on data from the previous calendar year.
13On the basis of the reconciliation, the department shall make any necessary
14adjustments in premiums, insurer assessments or provider payment rates for the
15fiscal year beginning on the first July 1 after the reconciliation, as provided in sub.
16(2) (b).
SB45-SSA1,1166,2117 (b) Except as provided in sub. (3) and s. 149.144, the department shall adjust
18the provider payment rates to meet the providers' specified portion of the plan costs
19no more than once annually. The department may not determine the adjustment on
20an individual provider basis or on the basis of provider type, but shall determine the
21adjustment for all providers in the aggregate.
SB45-SSA1, s. 2267r 22Section 2267r. 149.144 of the statutes is amended to read:
SB45-SSA1,1167,11 23149.144 Adjustments to insurer assessments and provider payment
24rates for premium and deductible reductions.
If the moneys transferred to the
25fund under the appropriation
under s. 20.435 (5) (4) (ah) are insufficient to reimburse

1the plan for premium reductions under s. 149.165 and deductible reductions under
2s. 149.14 (5) (a), or the department determines that the moneys transferred or to be
3transferred to the fund under the appropriation
under s. 20.435 (5) (4) (ah) will be
4insufficient to reimburse the plan for premium reductions under s. 149.165 and
5deductible reductions under s. 149.14 (5) (a), the department shall may, by rule,
6adjust in equal proportions the amount of the assessment set under s. 149.143 (2) (a)
73. and the provider payment rate set under s. 149.143 (2) (a) 4., subject to s. 149.143
8(1) (b) 1., sufficient to reimburse the plan for premium reductions under s. 149.165
9and deductible reductions under s. 149.14 (5) (a). The If the department makes the
10adjustment under this section, the
department shall notify the commissioner so that
11the commissioner may levy any increase in insurer assessments.
SB45-SSA1, s. 2268m 12Section 2268m. 149.145 of the statutes is amended to read:
SB45-SSA1,1167,23 13149.145 Program budget. The department, in consultation with the board,
14shall establish a program budget for each plan year. The program budget shall be
15based on the provider payment rates specified in s. 149.15 (3) (e) 149.142 and in the
16most recent provider contracts that are in effect and on the funding sources specified
17in s. 149.143 (1), including the methodologies specified in ss. 149.143, 149.144 and
18149.146 for determining premium rates, insurer assessments and provider payment
19rates. Except as otherwise provided in s. 149.143 (3) (a) and (b), from the program
20budget the department shall derive the actual provider payment rate for a plan year
21that reflects the providers' proportional share of the plan costs, consistent with ss.
22149.143 and 149.144. The department may not implement a program budget
23established under this section unless it is approved by the board.
SB45-SSA1, s. 2269 24Section 2269. 149.146 (1) (a) of the statutes is amended to read:
SB45-SSA1,1168,4
1149.146 (1) (a) Beginning on January 1, 1998, in addition to the coverage
2required under s. 149.14, the plan shall offer to all eligible persons who are not
3eligible for medicare
a choice of coverage, as described in section 2744 (a) (1) (C), P.L.
4104-191. Any such choice of coverage shall be major medical expense coverage.
SB45-SSA1, s. 2270 5Section 2270. 149.146 (1) (b) 2. of the statutes is amended to read:
SB45-SSA1,1168,146 149.146 (1) (b) 2. An eligible person under par. (a) may elect once each year, at
7the time and according to procedures established by the department, among the
8coverages offered under this section and s. 149.14. If an eligible person elects new
9coverage, any preexisting condition exclusion imposed under the new coverage is met
10to the extent that the eligible person has been previously and continuously covered
11under this chapter. No preexisting condition exclusion may be imposed on an eligible
12person who elects new coverage if the person was an eligible individual when first
13covered under this chapter and the person remained continuously covered under this
14chapter up to the time of electing the new coverage.
SB45-SSA1, s. 2271 15Section 2271. 149.146 (2) (am) of the statutes is created to read:
SB45-SSA1,1168,1916 149.146 (2) (am) 1. For all eligible persons with coverage under this section,
17the deductible shall be $2,500. Expenses used to satisfy the deductible during the
18last 90 days of a calendar year shall also be applied to satisfy the deductible for the
19following calendar year.
SB45-SSA1,1168,2320 2. Except as provided in subd. 3., if the covered costs incurred by the eligible
21person exceed the deductible for major medical expense coverage in a calendar year,
22the plan shall pay at least 80% of any additional covered costs incurred by the person
23during the calendar year.
SB45-SSA1,1169,324 3. If the aggregate of the covered costs not paid by the plan under subd. 2. and
25the deductible exceeds $3,500 for any eligible person during a calendar year or $7,000

1for all eligible persons in a family, the plan shall pay 100% of all covered costs
2incurred by the eligible person during the calendar year after the payment ceilings
3under this subdivision are exceeded.
SB45-SSA1,1169,84 4. Notwithstanding subds. 1. to 3., the department may establish different
5deductible amounts, a different coinsurance percentage and different covered costs
6and deductible aggregate amounts from those specified in subds. 1. to 3. in
7accordance with cost containment provisions established by the department under
8s. 149.17 (4).
SB45-SSA1, s. 2276m 9Section 2276m. 149.15 (3) (e) of the statutes is repealed.
SB45-SSA1, s. 2277c 10Section 2277c. 149.15 (3) (g) of the statutes is created to read:
SB45-SSA1,1169,1411 149.15 (3) (g) Establish oversight committees to address various
12administrative issues, such as financial management of the plan and plan
13administrator performance standards. A representative of the department may not
14be the chairperson of any committee established under this paragraph.
SB45-SSA1, s. 2277d 15Section 2277d. 149.16 (4) of the statutes is created to read:
SB45-SSA1,1169,1716 149.16 (4) The plan administrator shall account for costs related to the plan
17separately from costs related to medical assistance under subch. IV of ch. 49.
SB45-SSA1, s. 2277f 18Section 2277f. 149.16 (5) of the statutes is created to read:
SB45-SSA1,1169,2019 149.16 (5) The department shall obtain the approval of the board before
20implementing any contract with the plan administrator.
SB45-SSA1, s. 2278b 21Section 2278b. 149.165 (4) of the statutes is amended to read:
SB45-SSA1,1169,2422 149.165 (4) The department shall reimburse the plan for premium reductions
23under sub. (2) and deductible reductions under s. 149.14 (5) (a) with moneys
24transferred to the fund from the appropriation account under s. 20.435 (5) (4) (ah).
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