SB90: Bill Text

SB90,7,24 (4) "Disability insurance policy" has the meaning given in s. 632.895 (1) (a).

SB90,8,9 (5) "Health care facility" means a facility, as defined in s. 647.01 (4), or any hospital, nursing home, community-based residential facility, county home, county infirmary, county hospital, county mental health center, community health center, primary health center, tuberculosis sanatorium, adult family home, assisted living facility, rural medical center, hospice, or other place licensed, certified, or approved by the department of health and family services under s. 49.70, 49.71, 49.72, 50.02, 50.03, 50.032, 50.033, 50.034, 50.35, 50.52, 50.92 (2), 51.08, or 51.09 or a facility under s. 45.365, 51.05, 51.06, or 252.10 or ch. 233, or licensed or certified by a county department under s. 50.032 or 50.033.

SB90,8,11 (6) "Health care provider" means a provider of health care services or other benefits in this state that are specified under s. 152.10 (4).

SB90,8,13 (7) "Medicare" means coverage under part A or part B of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395ddd.

SB90,8,15 (8) "Reimbursement" means payment for the provision of services and other benefits that are specified under s. 152.10 (4).

SB90,8,16 (9) "Secretary" means the secretary of health planning and finance.

SB90,8,17 (10) "Veteran" has the meaning given in 38 USC 101 (2).

SB90,8,25 152.10 Universal health plan. (1) There is created a universal health plan in this state, under which, beginning on July 1, 2006, each eligible person shall receive reasonable medical service necessary to maintain health, enable diagnosis, or provide treatment or rehabilitation for an injury, condition, disability, or disease, for which reimbursement shall be made by the department, except that no coverage is provided for orthodontia or for the performance of reconstructive or cosmetic surgery that is not determined to be medically necessary under criteria that are promulgated as rules by the department.

SB90,9,5 (2) Each individual in this state who meets requirements of residency, under criteria promulgated as rules by the department, is eligible for coverage, except as provided in sub. (5), under the universal health plan, except that all of the following may be phased in for eligibility under this subsection, beginning no later than July 1, 2007:

SB90,9,7 (a) Individuals, other than those specified in par. (b), who have no coverage under disability insurance policies.

SB90,9,11 (b) Individuals who have no coverage under disability insurance policies and who receive health care, treatment for nervous or mental disorders, or treatment or prevention services for alcohol and other drug abuse that are funded by state or local funding.

SB90,9,15 (c) Individuals who are employees of the state or any county, city, village, or town, and who, as a benefit of the employment, have coverage for themselves and family members under provisions of group disability insurance policies or under self-insured health plans.

SB90,9,18 (d) Individuals, other than those specified in par. (c) or (h), who, by reason of their employment or as family members of individuals who are employed, have coverage under group disability insurance policies.

SB90,9,20 (e) Individuals who have coverage under individual disability insurance policies.

SB90,9,22 (f) Individuals who have coverage under the health insurance risk-sharing plan under ch. 149.

SB90,9,24 (g) Individuals who are eligible for benefits or services under s. 49.46, 49.468, 49.47, or 49.665, Medicare, or block grants that provide health care services.

SB90,10,3 (h) Individuals who are employees of self-insured employers, other than those specified in par. (c), and who receive health care benefits for themselves and family members under self-insured health plans.

SB90,10,4 (i) Individuals who receive medical benefits under worker's compensation.

SB90,10,7 (j) Veterans who receive medical benefits under s. 45.351 (1j) or 38 USC 1701 to 1774, or both, and the children of veterans who receive medical benefits under 38 USC 1801 to 1806.

SB90,10,8 (k) Indians who receive health and other services under 25 USC 1651 to 1683.

SB90,10,11 (3) (a) Any individual who is eligible under sub. (2) may receive services that are available under the universal health plan from any participating health care provider in this state.

SB90,10,14 (b) No individual who is eligible under sub. (2) may under this section be required to pay an amount as a deductible or copayment as a condition for receipt of services under this section from a health care facility or health care provider.

SB90,10,18 (c) An individual's state residency is presumed unless rebutted by clear and convincing evidence. If the presumption is so rebutted, any reimbursement paid under the universal health plan for health care services rendered to the individual is a liability of the individual.

SB90,10,20 (4) Health care services and other benefits provided under the universal health plan shall include all of the following:

SB90,10,22 (a) Services of all persons licensed, certified, registered, or permitted to treat the sick under chs. 441, 446, 447, 448, 449, 450, 451, 455, 457, and 459.

SB90,10,24 (b) Health care services that are provided by health care facilities and the offices and clinics of persons under par. (a).

SB90,11,2 (c) Preventive health care services and health promotional programs, including well-child care, immunizations, screening, outreach, and education.

SB90,11,5 (d) Medical or surgical supplies and durable medical or surgical equipment, supplies and appliances, including valves, pacemakers, prostheses, eyeglasses, and hearing aids.

SB90,11,8 (e) Prescription drugs specified in the listing of approved medicinal substances and formulae under s. 152.40 (4) (m) and any other drugs specified by the department by rule.

SB90,11,9 (f) Blood and blood products.

SB90,11,14 (g) Long-term care services that are necessary for the physical health, mental and emotional well-being, and social and personal needs of individuals who have limited self-care capabilities, including services of health care facilities; home health care; hospice care; home-based and community-based services, including personal assistance and attendant care; and periodic needs assessments.

SB90,11,16 (h) Mental health treatment and services, including substance abuse and brain injury treatment.

SB90,11,17 (i) Dental services, as specified under s. 49.46 (2) (b) 1.

SB90,11,20 (5) The universal health plan is the payer of last resort, and coverage under the universal health plan is supplemental to any health care coverage in force that is held by an individual.

SB90,11,24 (6) As a condition of participation by a health care provider in the universal health plan, the health care provider shall accept reimbursement only under the universal health plan for all services or other benefits that the health care provider provides under the universal health plan.

SB90,12,3 152.20 Health policy board; powers and duties. (1) The board shall approve and continually evaluate the listing of approved medicinal substances and formulae that is required under s. 152.40 (4) (m).

SB90,12,6 (2) The board shall biennially evaluate and oversee cost containment guidelines and policies, including the evaluation of mechanisms used to contain costs of providing services, and shall revise the guidelines and policies as necessary.

SB90,12,8 (3) The board shall review all of the following issues and formulate or revise policies, as appropriate, with respect to the issues:

SB90,12,9 (a) Duties of the department that require policy determinations.

SB90,12,12 (b) The sources and amounts of revenues for the administration of the department and the board and for financing the payment of medical services that are provided to residents under the universal health plan.

SB90,12,13 (c) Information provided by the regional health councils.

SB90,12,17 (d) Development of a system for determination and periodic review of areas in this state, and specific populations within those areas, that are medically underserved; and development of plans for providing health care services to those areas and populations, including the establishment of community health centers.

SB90,12,20 (e) Development of a system for periodic reviews and evaluations of all aspects of the operation of the universal health plan, including the adequacy, cost, effectiveness, and quality of health care services provided.

SB90,12,23 (f) Development of a notice and hearing procedure for review of complaints of residents about the universal health plan, in accordance with the requirements of ch. 227.

SB90,12,25 (g) Other issues that the board determines are relevant to the universal health plan.

SB90,13,1 (h) State statutory changes that may be necessary to effect pars. (a) to (g).

SB90,13,5 (4) By January 1, April 1, July 1, and October 1 of each year, the board shall report to the governor on the revenues and expenditures of the universal health plan for the calendar quarter immediately preceding the most recently completed calendar quarter.

SB90,13,8 (5) The board shall establish provider payment rates, taking into consideration regional, rural, and urban differences, and conditions of payment for the provision of health care services under the universal health plan.

SB90,13,10 152.30 Regional health councils. (1) Each regional health council shall do all of the following:

SB90,13,15 (a) Elect one member of the regional health council to serve as a member of the board under s. 15.20 (1). If the term of the member who is so elected expires with respect to the regional health council or with respect to the board under s. 15.20 (1), the regional health council shall elect a current member of the council to serve as a member of the board in his or her stead.

SB90,13,19 (b) Study and continuously monitor the delivery and quality of and access to health care services in the region of the regional health council and recommend to the board ways to improve the quality of and help ensure access to health care services.

SB90,13,22 (c) Recommend to the board payment rates and conditions appropriate to specific regional needs and advise on regional health care policy issues and administrative policies and procedures.

SB90,13,25 (d) Study and continuously monitor the unmet health care service needs in the region of the regional health council and recommend to the board ways by which the needs may be met.

SB90,14,4 (e) Report at least annually to the board with respect to the health care needs, problems, and concerns of the region, including any issues elicited at public hearings under par. (g), and provide to the board recommendations to alleviate these needs, problems, and concerns.

SB90,14,7 (f) Require reports from and advise the member of the staff of the appropriate regional office whose duties are specified under s. 152.40 (1), concerning issues that arise under pars. (b) to (e).

SB90,14,11 (g) In at least 3 localities of the region, hold public hearings at least annually to elicit public opinion concerning the universal health plan. The council shall give notice of each hearing by publishing a class 1 notice, under ch. 985, at least 15 days before the hearing in a newspaper covering the affected area.

SB90,14,12 (h) Perform other duties as required by the board.

SB90,14,15 (2) Each regional health council may, for cause, recall the member elected under sub. (1) (a) and may elect another member to fulfill that term on the board if all of the following are done:

SB90,14,17 (a) The elected member of the board for whom recall is sought receives notice of the recall at least 10 working days before the meeting at which recall is voted upon.

SB90,14,20 (b) Notice of the vote to recall the elected member is made on the agenda of the meeting of the regional health council that is immediately prior to the meeting at which recall is voted upon.

SB90,14,23 (3) The staff of the appropriate regional office shall provide services to each regional health council to deal with issues of health consumer advocacy and health ombudsman functions.

SB90,15,3 152.40 Department of health planning and finance. (1) The department shall administer the universal health plan, including establishing a regional office in each of the regions specified under s. 15.207 (1) (a) 1. to 6. Each regional office shall have at least one staff member who acts in a full-time capacity as a regional consumer advocate and health care ombudsman.

SB90,15,5 (2) The department shall, after review and approval by the board, promulgate as rules all of the following:

SB90,15,8 (a) Guidelines for cost containment under the universal health plan, including the purchasing and distribution of major diagnostic, medical, and surgical equipment.

SB90,15,10 (b) Criteria for determining state residency for the purposes of eligibility under the universal health plan.

SB90,15,14 (c) Criteria, as recommended by the medical advisory committee appointed by the secretary under sub. (5), for determining medical necessity for orthodontia and for the performance of reconstructive or cosmetic surgery for coverage under the universal health plan.

SB90,15,16 (3) The department shall biennially evaluate and recommend to the board cost control measures for the universal health plan.

SB90,15,19 (4) The department shall, by July 1, 2005, begin implementation of processes, in light of policies formulated or revised under s. 152.20 (3), to effect all of the following:

SB90,15,23 (a) Specification of the amounts and sources of revenues to finance payment to providers under the universal health plan, which may not include any premiums, copayments, deductibles, and other forms of direct payment by patients, and which shall include all of the following:

SB90,16,4 1. Use of federal, state, and local moneys that fund, as of July 1, 2006, health care services, including medicare, medical assistance, health care services funded by a relief block grant under s. 49.02 or 49.025, health care services under s. 49.665, veterans medical benefits, Indian health care, services provided under federal block grants, alcohol and other drug abuse services, and services provided by local health departments.

SB90,16,9 2. Use of revenues from a tax on employers, based on the amount of wages that they pay, that generates, in the aggregate, revenues that are at least equal to amounts that employers contribute, as of the effective date of this subdivision .... [revisor inserts date], for employee health care benefit costs, including the costs of worker's compensation attributable to health care for injured employees.

SB90,16,13 3. Use of revenues from a graduated income tax on individuals that generates, in the aggregate, revenues that are not greater than expenditures that individuals make, as of July 1, 2006, for health care costs for which coverage under disability insurance policies is not obtained.

SB90,16,16 4. An indexing of the sources of revenues under this paragraph that provides for revenue growth that is equivalent to the anticipated growth of health care costs under the universal health plan.

SB90,16,19 (b) Application for waivers to 42 USC 1396 to 1396v or consideration of the feasibility of statutory changes to 42 USC 1396 to 1396v in order to effect all of the following:

SB90,16,21 1. Administration of the Medical Assistance program in this state by the department, rather than by the department of health and family services.

SB90,16,23 2. Use of federal financial participation to fund a portion of the administrative costs, after June 30, 2006, of the department.

SB90,17,3 3. Use of federal financial participation, after June 30, 2006, to fund, under the universal health plan, the health care services received by a percentage of the residents that corresponds to the percentage of the residents, as determined by the board, that is eligible to receive health care services under the Medical Assistance program on July 1, 2006.

SB90,17,5 4. The formulation of criteria and procedures for payment of out-of-state health care costs incurred by residents specified in subd. 3.

SB90,17,7 5. Use of federal financial participation to fund the scope, or a portion of the scope, of medical services to be provided under the universal health plan.

SB90,17,9 (c) Application for waivers to Medicare or consideration of the feasibility of statutory changes to 42 USC 1395 to 1395ddd in order to effect all of the following:

SB90,17,11 1. Administration of the Medicare program in this state by the department, rather than by private insurers.

SB90,17,13 2. Use of federal Medicare funds to fund a portion of the administrative costs, after June 30, 2006, of the department.

SB90,17,16 3. Use of federal Medicare funds to fund, under the universal health plan, the health care services received by residents who are eligible to receive services under Medicare beginning on July 1, 2006.

SB90,17,18 4. The formulation of criteria and procedures for payment of out-of-state health care costs incurred by residents specified in subd. 3.

SB90,17,20 5. Use of federal Medicare funds to fund the scope, or a portion of the scope, of medical services to be provided under the universal health plan.

SB90,17,22 6. The assignment to the state, as represented by the department, of rights of an individual to payment for medical care from any 3rd party.

SB90,18,2 (d) Application for waivers or consideration of the feasibility of statutory changes to federal laws, other than those specified in pars. (b) and (c), in order to use moneys available under those federal laws for payment of health care services under the universal health plan or in order to provide services to all residents under the universal health plan.

SB90,18,5 (e) The establishment and maintenance, with reserves of no less than 5% of the total annual amount appropriated under s. 20.430 (1) (b), of a health trust fund in the department, for receipt of revenues specified in par. (a).

SB90,18,13 (f) The formulation of criteria for determining payment and the formulation of procedures for determining payment and negotiating applicable rates to be used for payment for health care providers, including health care facilities, under the universal health plan. The criteria and procedures for determining payment shall include periodic overall budgeting, including separately budgeting for operational costs; for health care facilities and services; for negotiations with professional groups or associations of practitioners; for consideration of inflation costs and increased patient populations; and for research and teaching.