AB100-ASA1,803,1613
(b) The board controls the assets of the fund and shall select regulated financial
14institutions in this state that receive deposits in which to establish and maintain
15accounts for assets needed on a current basis. If practicable, the accounts shall earn
16interest.
AB100-ASA1,803,1817
(c) Moneys in the fund may be expended only for the purposes specified in par.
18(a).
AB100-ASA1,803,24
19(3) Immunity. No cause of action of any nature may arise against and no
20liability may be imposed upon the organization, plan, or board; or any agent,
21employee, or director of any of them; or contributor insurers; or the commissioner;
22or any of the commissioner's agents, employees, or representatives, for any act or
23omission by any of them in the performance of their powers and duties under this
24chapter.
AB100-ASA1,804,5
1149.115 Rules relating to creditable coverage. The commissioner
, in
2consultation with the department, shall promulgate rules that specify how
3creditable coverage is to be aggregated for purposes of s. 149.10 (2t) (a) and that
4determine the creditable coverage to which s. 149.10 (2t) (b) and (d) applies. The
5rules shall comply with section 2701 (c) of P.L.
104-191.
AB100-ASA1,804,147
149.12
(1) (intro.) Except as provided in subs. (1m)
and, (2)
, and (3), the board
8or plan administrator shall certify as eligible a person who is covered by
medicare 9Medicare because he or she is disabled under
42 USC 423, a person who submits
10evidence that he or she has tested positive for the presence of HIV, antigen or
11nonantigenic products of HIV
, or an antibody to HIV, a person who is an eligible
12individual, and any person who receives and submits any of the following based
13wholly or partially on medical underwriting considerations within 9 months prior to
14making application for coverage by the plan:
AB100-ASA1,804,1616
149.12
(1) (a) A notice of rejection of coverage from
one 2 or more insurers.
AB100-ASA1,804,2118
149.12
(1m) The board
or plan administrator may not certify a person as
19eligible under circumstances requiring notice under sub. (1) (a) to (d) if the required
20notices were issued by an insurance intermediary who is not acting as an
21administrator, as defined in s. 633.01.
AB100-ASA1,804,2423
149.12
(2) (g) A person is not eligible for coverage under the plan if the person
24is eligible for any of the following:
AB100-ASA1,804,2525
1. Services under s. 46.27 (11), 46.275, 46.277, or 46.278.
AB100-ASA1,805,2
12. Medical assistance provided as part of a family care benefit, as defined in s.
246.2805 (4).
AB100-ASA1,805,433. Services provided under a waiver requested under
2001 Wisconsin Act 16,
4section
9123 (16rs), or
2003 Wisconsin Act 33, section
9124 (8c).
AB100-ASA1,805,65
4. Services provided under the program of all-inclusive care for persons aged
655 or older authorized under
42 USC 1396u-4.
AB100-ASA1,805,87
5. Services provided under the demonstration program under a federal waiver
8authorized under
42 USC 1315.
AB100-ASA1,805,109
6. Health care coverage under the Badger Care health care program under s.
1049.665.
AB100-ASA1,805,1712
149.12
(3) (a) Except as provided in pars. (b)
to (c) and (bm), no person is eligible
13for coverage under the plan for whom a premium, deductible
, or coinsurance amount
14is paid or reimbursed by a federal, state, county
, or municipal government or agency
15as of the first day of any term for which a premium amount is paid or reimbursed and
16as of the day after the last day of any term during which a deductible or coinsurance
17amount is paid or reimbursed.
AB100-ASA1,805,2420
149.12
(4) Subject to subs. (1m), (2), and (3), the board may establish criteria
21that would enable additional persons to be eligible for coverage under the plan. The
22board shall ensure that any expansion of eligibility is consistent with the purpose of
23the plan to provide health care coverage for those who are unable to obtain health
24insurance in the private market and does not endanger the solvency of the plan.
AB100-ASA1,806,2
1(5) The board shall establish policies for determining and verifying the
2continued eligibility of an eligible person.
AB100-ASA1,806,84
149.13
(1) Every insurer shall participate in the cost of administering the plan,
5except the commissioner may by rule exempt as a class those insurers whose share
6as determined under sub. (2) would be so minimal as to not exceed the estimated cost
7of levying the assessment. The commissioner shall advise the
department board of
8the insurers participating in the cost of administering the plan.
AB100-ASA1,806,1410
149.13
(3) (a) Each insurer's proportion of participation under sub. (2) shall be
11determined annually by the commissioner based on annual statements and other
12reports filed by the insurer with the commissioner. The commissioner shall assess
13an insurer for the insurer's proportion of participation based on the total
14assessments estimated by the
department under s. 149.143 (2) (a) 3. board.
AB100-ASA1,806,2216
149.13
(3) (b) If the
department
board or the commissioner finds that the
17commissioner's authority to require insurers to report under chs. 600 to 646 and 655
18is not adequate to permit
the department, the commissioner or the board to carry out
19the
department's, commissioner's or board's responsibilities under this chapter, the
20commissioner shall promulgate rules requiring insurers to report the information
21necessary for the
department, commissioner and board to make the determinations
22required under this chapter.
AB100-ASA1,807,224
149.13
(4) Notwithstanding subs. (1) to (3), the
department board, with the
25agreement of the commissioner, may perform various administrative functions
1related to the assessment of insurers participating in the cost of administering the
2plan.
AB100-ASA1,807,74
149.14
(1) (a) The plan shall offer
coverage for each eligible person in an
5annually renewable policy
the coverage specified in this section for each eligible
6person. If an eligible person is also eligible for
medicare Medicare coverage, the plan
7shall not pay or reimburse any person for expenses paid for by
medicare Medicare.
AB100-ASA1,807,159
149.14
(2) (a) The plan shall provide every eligible person who is not eligible
10for
medicare Medicare with major medical expense coverage. Major medical expense
11coverage offered under the plan under this section shall pay an eligible person's
12covered expenses, subject to
sub. (3) and deductible, copayment
, and coinsurance
13payments
authorized under sub. (5), up to a lifetime limit of $1,000,000 per covered
14individual.
The maximum limit under this paragraph shall not be altered by the
15board, and no actuarially equivalent benefit may be substituted by the board.
AB100-ASA1, s. 2045c
16Section 2045c. 149.14 (3) (intro.) of the statutes is renumbered 149.14 (3) and
17amended to read:
AB100-ASA1,808,518
149.14
(3) Covered expenses. Except as provided in sub. (4), except as
19restricted by cost containment provisions under s. 149.17 (4) and except as reduced
20by the department under ss. 149.143 and 149.144, covered Covered expenses for
the 21coverage under
this section the plan shall be the payment rates established by the
22department under s. 149.142 board for
the services provided by persons licensed
23under ch. 446 and certified under s. 49.45 (2) (a) 11.
Except as provided in sub. (4),
24except as restricted by cost containment provisions under s. 149.17 (4) and except as
25reduced by the department under ss. 149.143 and 149.144, covered
Covered expenses
1for
the coverage under
this section the plan shall also be the payment rates
2established by the
department under s. 149.142 board for
the following services and
3articles if the service or article is prescribed by a physician who is licensed under ch.
4448 or in another state and who is certified under s. 49.45 (2) (a) 11. and if the service
5or article is provided by a provider certified under s. 49.45 (2) (a) 11.
:
AB100-ASA1,808,138
149.14
(4) Benefit design. Except as provided in subs. (2) (a) and (6), the board
9shall determine the benefit design of the plan, including the covered expenses,
10expenses excluded from coverage, deductibles, copayments, coinsurance,
11out-of-pocket limits, and coverage limitations. The board may establish more than
12one benefit design under the plan. All benefit designs shall be comparable to typical
13individual health insurance policies offered in the private sector market in this state.
AB100-ASA1, s. 2047c
15Section 2047c. 149.14 (4m) of the statutes is renumbered 149.142 (2m) and
16amended to read:
AB100-ASA1,808,2217
149.142
(2m) Payment is payment in full. Except for copayments, coinsurance
, 18or deductibles required or authorized under the plan, a provider of a covered service
19or article shall accept as payment in full for the covered service or article the payment
20rate determined under
ss. 149.142, 149.143 and 149.144
sub. (1) and may not bill an
21eligible person who receives the service or article for any amount by which the charge
22for the service or article is reduced under
s. 149.142, 149.143 or 149.144 sub. (1).
AB100-ASA1,809,63
149.14
(7) (b) The
department organization has a cause of action against an
4eligible participant for the recovery of the amount of benefits paid which are not for
5covered expenses under the plan. Benefits under the plan may be reduced or refused
6as a setoff against any amount recoverable under this paragraph.
AB100-ASA1,809,118
149.14
(7) (c) The
department organization is subrogated to the rights of an
9eligible person to recover special damages for illness or injury to the person caused
10by the act of a 3rd person to the extent that benefits are provided under the plan.
11Section 814.03 (3) applies to the
department organization under this paragraph.
AB100-ASA1,809,1513
149.14
(8) Subsidies. The board shall provide for subsidies for premiums,
14deductibles, and copayments for eligible persons with household incomes below a
15level established by the board.
AB100-ASA1,809,19
17149.141 Premiums. The board shall set premiums for coverage under the
18plan at a level that is sufficient to cover 60 percent of plan costs, as provided in s.
19149.143 (1).
AB100-ASA1, s. 2051m
20Section 2051m. 149.142 (1) (a) of the statutes is renumbered 149.142 (1) and
21amended to read:
AB100-ASA1,810,722
149.142
(1) Establishment of rates.
Except as provided in par. (b), the
23department The board shall establish
provider payment rates for covered expenses
24that consist of the allowable charges paid under s. 49.46 (2) for the services and
25articles provided plus an enhancement determined by the
department board. The
1rates shall be based on the allowable charges paid under s. 49.46 (2), projected plan
2costs
, and trend factors. Using the same methodology that applies to medical
3assistance under subch. IV of ch. 49, the
department
board shall establish hospital
4outpatient per visit reimbursement rates and hospital inpatient reimbursement
5rates that are specific to diagnostically related groups of eligible persons.
The
6adjustments to the usual and customary rates shall be sufficient to cover 20 percent
7of plan costs, as provided in s. 149.143 (3).
AB100-ASA1,810,12
11149.143 Payment of plan costs. The board shall pay plan costs, including
12any premium, deductible, and copayment subsidies, as follows:
AB100-ASA1,810,13
13(1) Sixty percent from premiums paid by eligible persons.
AB100-ASA1,810,14
14(2) Twenty percent from insurer assessments under s. 149.13.
AB100-ASA1,810,16
15(3) Twenty percent from adjustments to provider payment rates under s.
16149.142.
AB100-ASA1, s. 2054m
19Section 2054m. 149.146 (1) (a) and (b) of the statutes are consolidated,
20renumbered 149.14 (2) (c) and amended to read:
AB100-ASA1,811,921
149.14
(2) (c)
Beginning on January 1, 1998, in In addition to the coverage
22required under
s. 149.14 pars. (a) and (b), the plan shall offer to all eligible persons
23who are not eligible for
medicare Medicare a choice of coverage, as described in
24section 2744 (a) (1) (C), P.L.
104-191. Any such choice of coverage shall be major
25medical expense coverage.
(b) An eligible person
under par. (a) who is not eligible
1for Medicare may elect once each year, at the time and according to procedures
2established by the
department board, among the coverages offered under this
section
3and s. 149.14. If an eligible person elects new coverage, any preexisting condition
4exclusion imposed under the new coverage is met to the extent that the eligible
5person has been previously and continuously covered under this chapter. No
6preexisting condition exclusion may be imposed on an eligible person who elects new
7coverage if the person was an eligible individual when first covered under this
8chapter and the person remained continuously covered under this chapter up to the
9time of electing the new coverage paragraph and par. (a).
AB100-ASA1,811,13
13149.155 Additional duties of board. The board shall do all of the following:
AB100-ASA1,811,15
14(1) Adopt policies for the administration of this chapter, including delegation
15of any part of its powers and its own procedures.
AB100-ASA1,811,17
16(5) Seek to qualify the plan as a state pharmacy assistance program, as defined
17in
42 CFR 423.464.
AB100-ASA1,811,19
18(6) Annually submit a report to the legislature under s. 13.172 (2) and to the
19governor on the operation of the plan.
AB100-ASA1, s. 2057m
22Section 2057m. 149.16 (3) (a) of the statutes is renumbered 149.155 (2) and
23amended to read:
AB100-ASA1,811,2524
149.155
(2) The plan administrator shall perform Perform all eligibility and
25administrative claims payment functions relating to the plan.
AB100-ASA1, s. 2058c
1Section 2058c. 149.16 (3) (b) of the statutes is renumbered 149.155 (3) and
2amended to read:
AB100-ASA1,812,53
149.155
(3) The plan administrator shall establish Establish a premium billing
4procedure for collection of premiums from insured persons. Billings shall be made
5on a periodic basis as determined by the
department
board.
AB100-ASA1, s. 2058m
6Section 2058m. 149.16 (3) (c) of the statutes is renumbered 149.155 (4), and
7149.155 (4) (intro.), as renumbered, is amended to read:
AB100-ASA1,812,108
149.155
(4) (intro.)
The plan administrator shall perform Perform all necessary
9functions to assure timely payment of benefits to covered persons under the plan,
10including:
