Wisconsin Legislature: 25,2038m

149.10 (2j) (a) 3. Part A or, part B, or part D of title XVIII of the federal Social Security Act.

25,2034c Section 2034c. 149.10 (2m) of the statutes is repealed.

25,2034m Section 2034m. 149.10 (2t) (c) of the statutes is amended to read:

149.10 (2t) (c) The individual does not have creditable coverage and is not eligible for coverage under a group health plan, part A or, part B, or part D of title XVIII of the federal Social Security Act or a state plan under title XIX of the federal Social Security Act or any successor program.

25,2035c Section 2035c. 149.10 (3) of the statutes is amended to read:

149.10 (3) "Eligible person" means a resident of this state who qualifies under s. 149.12 whether or not the person is legally responsible for the payment of medical expenses incurred on the person's behalf.

25,2035m Section 2035m. 149.10 (3e) of the statutes is amended to read:

149.10 (3e) "Fund" means the health insurance risk-sharing plan Health Insurance Risk-Sharing Plan fund under s. 149.11 (2).

25,2036c Section 2036c. 149.10 (7) of the statutes is amended to read:

149.10 (7) "Medicare" means coverage under both part A and, part B, and part D of Title XVIII of the federal social security act, 42 USC 1395 et seq., as amended.

25,2036m Section 2036m. 149.10 (9) of the statutes is amended to read:

149.10 (9) "Resident" means a person who has been legally domiciled in this state for a period of at least 30 days 6 months or, with respect to an eligible individual, an individual who resides in this state. For purposes of this chapter, legal domicile is established by living in this state and obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin or filing a Wisconsin income tax return. A child is legally domiciled in this state if the child lives in this state and if at least one of the child's parents or the child's guardian is legally domiciled in this state. A person with a developmental disability or another disability which prevents the person from obtaining a Wisconsin motor vehicle operator's license, registering to vote in Wisconsin, or filing a Wisconsin income tax return, is legally domiciled in this state by living in this state.

25,2037c Section 2037c. 149.10 (10) of the statutes is repealed.

25,2037m Section 2037m. 149.11 of the statutes is repealed and recreated to read:

149.11 Administration of plan. (1) Appointment of board of directors; formation of administering organization. (a) No later than September 1, 2005, the commissioner shall nominate 13 individuals to be appointed with the advice and consent of the senate to serve as the initial directors of the board of the organization to be formed under par. (b). The board shall consist of 4 representatives of participating insurers; 4 representatives of health care providers, including one representative of the Wisconsin Medical Society, one representative of the Wisconsin Hospital Association, Inc., one representative of the Pharmacy Society of Wisconsin, and one representative of health care providers that provide services to persons with coverage under the plan; and 5 other members, at least one of whom represents small businesses that purchase private health insurance and at least one of whom is a person with coverage under the plan. In making the nominations to the board, the commissioner shall first consult with one or more trade or professional associations whose members include participating insurers, one or more trade or professional associations whose members include health care providers that provide services to persons with coverage under the plan, and one or more trade or professional associations whose members include small business owners.

(b) The individuals appointed as initial directors under par. (a) shall form a private, nonprofit organization under ch. 181 and shall take all actions necessary to exempt the organization from federal taxation under section 501 (a) of the Internal Revenue Code. The articles of incorporation shall include all of the following:

1. The names and addresses of the 13 individuals as the initial directors.

2. That the purpose of the organization is to administer the plan.

3. That the directors, including the initial directors, shall serve staggered 3-year terms.

4. That the directors shall satisfy the criteria specified in par. (a) and shall be nominated by the commissioner, after consultation as specified in par. (a), and appointed with the advice and consent of the senate.

(c) As a condition for the release of funds under s. 20.145 (5) (g), the organization, through the board, shall administer the plan in conformity with this chapter and perform any other duties required of the organization or board under this chapter.

(2) Fund. (a) The board shall pay the operating and administrative expenses of the plan from the fund, which shall be outside the state treasury and which shall consist of all of the following:

3. The earnings resulting from investments under par. (b).

4. Any other moneys received by the organization or board from time to time.

(b) The board controls the assets of the fund and shall select regulated financial institutions in this state that receive deposits in which to establish and maintain accounts for assets needed on a current basis. If practicable, the accounts shall earn interest.

(3) Immunity. No cause of action of any nature may arise against and no liability may be imposed upon the organization, plan, or board; or any agent, employee, or director of any of them; or contributor insurers; or the commissioner; or any of the commissioner's agents, employees, or representatives, for any act or omission by any of them in the performance of their powers and duties under this chapter.

25,2038c Section 2038c. 149.115 of the statutes is amended to read:

149.115 Rules relating to creditable coverage. The commissioner, in consultation with the department, shall promulgate rules that specify how creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The rules shall comply with section 2701 (c) of P.L. 104-191.

25,2038m Section 2038m. 149.12 (1) (intro.) of the statutes is amended to read:

149.12 (1) (intro.) Except as provided in subs. (1m) and, (2), and (3), the board or plan administrator shall certify as eligible a person who is covered by medicare Medicare because he or she is disabled under 42 USC 423, a person who submits evidence that he or she has tested positive for the presence of HIV, antigen or nonantigenic products of HIV, or an antibody to HIV, a person who is an eligible individual, and any person who receives and submits any of the following based wholly or partially on medical underwriting considerations within 9 months prior to making application for coverage by the plan:

25,2039c Section 2039c. 149.12 (1) (a) of the statutes is amended to read:

149.12 (1) (a) A notice of rejection of coverage from one 2 or more insurers.

25,2039m Section 2039m. 149.12 (1m) of the statutes is amended to read:

149.12 (1m) The board or plan administrator may not certify a person as eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required notices were issued by an insurance intermediary who is not acting as an administrator, as defined in s. 633.01.

25,2040c Section 2040c. 149.12 (2) (g) of the statutes is created to read:

149.12 (2) (g) A person is not eligible for coverage under the plan if the person is eligible for any of the following:

1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.

2. Medical assistance provided as part of a family care benefit, as defined in s. 46.2805 (4).

3. Services provided under a waiver requested under 2001 Wisconsin Act 16, section 9123 (16rs), or 2003 Wisconsin Act 33, section 9124 (8c).

4. Services provided under the program of all-inclusive care for persons aged 55 or older authorized under 42 USC 1396u-4.

5. Services provided under the demonstration program under a federal waiver authorized under 42 USC 1315.

6. Health care coverage under the Badger Care health care program under s. 49.665.

25,2040m Section 2040m. 149.12 (3) (a) of the statutes is amended to read:

149.12 (3) (a) Except as provided in pars. (b) to (c) and (bm), no person is eligible for coverage under the plan for whom a premium, deductible, or coinsurance amount is paid or reimbursed by a federal, state, county, or municipal government or agency as of the first day of any term for which a premium amount is paid or reimbursed and as of the day after the last day of any term during which a deductible or coinsurance amount is paid or reimbursed.

25,2041c Section 2041c. 149.12 (3) (c) of the statutes is repealed.

25,2041m Section 2041m. 149.12 (4) and (5) of the statutes are created to read:

149.12 (4) Subject to subs. (1m), (2), and (3), the board may establish criteria that would enable additional persons to be eligible for coverage under the plan. The board shall ensure that any expansion of eligibility is consistent with the purpose of the plan to provide health care coverage for those who are unable to obtain health insurance in the private market and does not endanger the solvency of the plan.

(5) The board shall establish policies for determining and verifying the continued eligibility of an eligible person.

25,2042c Section 2042c. 149.13 (1) of the statutes is amended to read:

149.13 (1) Every insurer shall participate in the cost of administering the plan, except the commissioner may by rule exempt as a class those insurers whose share as determined under sub. (2) would be so minimal as to not exceed the estimated cost of levying the assessment. The commissioner shall advise the department board of the insurers participating in the cost of administering the plan.

25,2042m Section 2042m. 149.13 (3) (a) of the statutes is amended to read:

149.13 (3) (a) Each insurer's proportion of participation under sub. (2) shall be determined annually by the commissioner based on annual statements and other reports filed by the insurer with the commissioner. The commissioner shall assess an insurer for the insurer's proportion of participation based on the total assessments estimated by the department under s. 149.143 (2) (a) 3. board.

25,2043c Section 2043c. 149.13 (3) (b) of the statutes is amended to read:

149.13 (3) (b) If the department board or the commissioner finds that the commissioner's authority to require insurers to report under chs. 600 to 646 and 655 is not adequate to permit the department, the commissioner or the board to carry out the department's, commissioner's or board's responsibilities under this chapter, the commissioner shall promulgate rules requiring insurers to report the information necessary for the department, commissioner and board to make the determinations required under this chapter.

25,2043m Section 2043m. 149.13 (4) of the statutes is amended to read:

149.13 (4) Notwithstanding subs. (1) to (3), the department board, with the agreement of the commissioner, may perform various administrative functions related to the assessment of insurers participating in the cost of administering the plan.

25,2044c Section 2044c. 149.14 (1) (a) of the statutes is amended to read:

149.14 (1) (a) The plan shall offer coverage for each eligible person in an annually renewable policy the coverage specified in this section for each eligible person. If an eligible person is also eligible for medicare Medicare coverage, the plan shall not pay or reimburse any person for expenses paid for by medicare Medicare.

25,2044m Section 2044m. 149.14 (2) (a) of the statutes is amended to read:

149.14 (2) (a) The plan shall provide every eligible person who is not eligible for medicare Medicare with major medical expense coverage. Major medical expense coverage offered under the plan under this section shall pay an eligible person's covered expenses, subject to sub. (3) and deductible, copayment, and coinsurance payments authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.

25,2045c Section 2045c. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and amended to read:

149.14 (3) Covered expenses. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall be the payment rates established by the department under s. 149.142 board for the services provided by persons licensed under ch. 446 and certified under s. 49.45 (2) (a) 11. Except as provided in sub. (4), except as restricted by cost containment provisions under s. 149.17 (4) and except as reduced by the department under ss. 149.143 and 149.144, covered Covered expenses for the coverage under this section the plan shall also be the payment rates established by the department under s. 149.142 board for the following services and articles if the service or article is prescribed by a physician who is licensed under ch. 448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service or article is provided by a provider certified under s. 49.45 (2) (a) 11.:

25,2045m Section 2045m. 149.14 (3) (a) to (r) of the statutes are repealed.

25,2046c Section 2046c. 149.14 (4) of the statutes is repealed and recreated to read:

149.14 (4) Benefit design. Except as provided in subs. (2) (a) and (6), the board shall determine the benefit design of the plan, including the covered expenses, expenses excluded from coverage, deductibles, copayments, coinsurance, out-of-pocket limits, and coverage limitations. The board may establish more than one benefit design under the plan. All benefit designs shall be comparable to typical individual health insurance policies offered in the private sector market in this state.

25,2046m Section 2046m. 149.14 (4c) of the statutes is repealed.

25,2047c Section 2047c. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and amended to read:

149.142 (2m) 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. 149.142, 149.143 and 149.144 sub. (1) 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. 149.142, 149.143 or 149.144 sub. (1).

25,2047m Section 2047m. 149.14 (5) of the statutes is repealed.

25,2048c Section 2048c. 149.14 (5m) of the statutes is repealed.

25,2048m Section 2048m. 149.14 (6) (a) of the statutes is repealed.

25,2049c Section 2049c. 149.14 (6) (b) of the statutes is renumbered 149.14 (6).

25,2049m Section 2049m. 149.14 (7) (b) of the statutes is amended to read:

149.14 (7) (b) The department organization has a cause of action against an eligible participant for the recovery of the amount of benefits paid which are not for covered expenses under the plan. Benefits under the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

25,2050c Section 2050c. 149.14 (7) (c) of the statutes is amended to read:

149.14 (7) (c) The department organization is subrogated to the rights of an eligible person to recover special damages for illness or injury to the person caused by the act of a 3rd person to the extent that benefits are provided under the plan. Section 814.03 (3) applies to the department organization under this paragraph.

25,2050m Section 2050m. 149.14 (8) of the statutes is repealed and recreated to read:

149.14 (8) Subsidies. The board shall provide for subsidies for premiums, deductibles, and copayments for eligible persons with household incomes below a level established by the board.

25,2051c Section 2051c. 149.141 of the statutes is created to read:

149.141 Premiums. The board shall set premiums for coverage under the plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s. 149.143 (1), except that in no event may plan rates exceed 200 percent of rates applicable to individual standard risks.

25,2051m Section 2051m. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and amended to read:

149.142 (1) Establishment of rates. Except as provided in par. (b), the department The board shall establish provider payment rates for covered expenses that consist of the allowable charges paid under s. 49.46 (2) for the services and articles provided plus an enhancement determined by the department board. The rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan costs, and trend factors. Using the same methodology that applies to medical assistance under subch. IV of ch. 49, the department board shall establish hospital outpatient per visit reimbursement rates and hospital inpatient reimbursement rates that are specific to diagnostically related groups of eligible persons. The adjustments to the usual and customary rates shall be sufficient to cover 20 percent of plan costs, as provided in s. 149.143 (3).

25,2052c Section 2052c. 149.142 (1) (b) of the statutes is repealed.

25,2052m Section 2052m. 149.142 (2) of the statutes is repealed.

25,2053c Section 2053c. 149.143 of the statutes is repealed and recreated to read:

149.143 Payment of plan costs. The board shall pay plan costs, including any premium, deductible, and copayment subsidies, as follows:

(1) Sixty percent from premiums paid by eligible persons.

(2) Twenty percent from insurer assessments under s. 149.13.