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Section 2041c. 149.12 (3) (c) of the statutes is repealed.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.
(3) Twenty percent from adjustments to provider payment rates under s. 149.142.
25,2053m
Section 2053m. 149.144 of the statutes is repealed.
25,2054c
Section 2054c. 149.145 of the statutes is repealed.
25,2054m
Section 2054m. 149.146 (1) (a) and (b) of the statutes are consolidated, renumbered 149.14 (2) (c) and amended to read:
149.14
(2) (c)
Beginning on January 1, 1998, in In addition to the coverage
required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons who are not eligible for
medicare Medicare a choice of coverage, as described in section 2744 (a) (1) (C), P.L.
104-191. Any such choice of coverage shall be major medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible for Medicare may elect once each year, at the time and according to procedures established by the
department board, among the coverages offered under this
section and s. 149.14. If an eligible person elects new coverage, any preexisting condition exclusion imposed under the new coverage is met to the extent that the eligible person has been previously and continuously covered under this chapter. No preexisting condition exclusion may be imposed on an eligible person who elects new coverage if the person was an eligible individual when first covered under this chapter and the person remained continuously covered under this chapter up to the time of electing the new coverage paragraph and par. (a).
25,2055c
Section 2055c. 149.146 (2) of the statutes is repealed.
25,2055m
Section 2055m. 149.15 of the statutes is repealed.
25,2056c
Section 2056c. 149.155 of the statutes is created to read:
149.155 Additional duties of board. The board shall do all of the following:
(1) Adopt policies for the administration of this chapter, including delegation of any part of its powers and its own procedures.
(5) Seek to qualify the plan as a state pharmacy assistance program, as defined in
42 CFR 423.464.
(6) Annually submit a report to the legislature under s. 13.172 (2) and to the governor on the operation of the plan.
25,2056m
Section 2056m. 149.16 (title) of the statutes is repealed.
25,2057c
Section 2057c. 149.16 (1m) of the statutes is repealed.
25,2057m
Section 2057m. 149.16 (3) (a) of the statutes is renumbered 149.155 (2) and amended to read:
149.155 (2) The plan administrator shall perform Perform all eligibility and administrative claims payment functions relating to the plan.
25,2058c
Section 2058c. 149.16 (3) (b) of the statutes is renumbered 149.155 (3) and amended to read:
149.155 (3) The plan administrator shall establish Establish a premium billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the department board.
25,2058m
Section 2058m. 149.16 (3) (c) of the statutes is renumbered 149.155 (4), and 149.155 (4) (intro.), as renumbered, is amended to read:
149.155 (4) (intro.) The plan administrator shall perform Perform all necessary functions to assure timely payment of benefits to covered persons under the plan, including:
25,2059c
Section 2059c. 149.16 (3) (e) of the statutes is repealed.
25,2059m
Section 2059m. 149.16 (4) of the statutes is repealed.
25,2060c
Section 2060c. 149.16 (5) of the statutes is repealed.
25,2060m
Section 2060m. 149.165 of the statutes is repealed.
25,2061c
Section 2061c. 149.17 (1) of the statutes is amended to read:
149.17 (1) Subject to ss. 149.14 (5m),
s. 149.143 and 149.146 (2) (b), a rating plan calculated in accordance with generally accepted actuarial principles.
25,2061m
Section 2061m. 149.17 (2) of the statutes is repealed.
25,2062c
Section 2062c. 149.17 (4) of the statutes is repealed.
25,2062m
Section 2062m. 149.175 of the statutes is repealed.
25,2063c
Section 2063c. 149.20 of the statutes is repealed.
25,2065
Section
2065. 149.25 of the statutes is repealed.
